- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $8,410.45
| Facility | | $4,686.85 | $4,686.85 | $8,410.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $5,653.69
| Professional | | $4,686.85 | $4,686.85 | $5,653.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,084.79 / $5,110.21 / $5,175.81
| Facility | | $5,084.79 | $5,110.21 | $5,175.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,322.07 / $5,102.59 / $5,148.35
| Professional | | $4,322.07 | $5,102.59 | $5,148.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,776.10 / $4,776.10 / $5,970.14
| Professional | | $4,776.10 | $4,776.10 | $5,970.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,389.08 / $4,672.47 / $7,943.20
| Facility | | $4,389.08 | $4,672.47 | $7,943.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,672.47 / $4,672.47 / $5,091.03
| Professional | | $4,672.47 | $4,672.47 | $5,091.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,983.82 / $4,686.85 / $5,090.14
| Professional | | $3,983.82 | $4,686.85 | $5,090.14 |