- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $8,027.30
| Professional | | $4,686.85 | $4,686.85 | $8,027.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,305.87 / $5,305.87 / $5,305.87
| Facility | | $5,305.87 | $5,305.87 | $5,305.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,421.56 / $5,306.78 / $8,844.64
| Facility | | $4,421.56 | $5,306.78 | $8,844.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $4,686.85
| Professional | | $4,686.85 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,421.56 / $5,306.78 / $8,844.64
| Facility | | $4,421.56 | $5,306.78 | $8,844.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,686.85 / $4,686.85 / $4,686.85
| Professional | | $4,686.85 | $4,686.85 | $4,686.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,452.51 / $4,686.85 / $5,985.67
| Professional | | $4,452.51 | $4,686.85 | $5,985.67 |