- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $5,351.02
| Facility | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,162.16 / $5,351.02 / $8,898.37
| Professional | | $5,162.16 | $5,351.02 | $8,898.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,048.61 / $3,699.63 / $4,977.18
| Facility | | $3,048.61 | $3,699.63 | $4,977.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $5,351.02
| Facility | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $6,921.80
| Professional | | $5,351.02 | $5,351.02 | $6,921.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,855.30 / $4,855.30 / $5,923.47
| Facility | | $4,855.30 | $4,855.30 | $5,923.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,246.10 / $5,246.10 / $5,246.10
| Professional | | $5,246.10 | $5,246.10 | $5,246.10 |