- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $6,584.43
| Facility | | $5,351.02 | $5,351.02 | $6,584.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,351.02 / $5,351.02 / $5,351.02
| Professional | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,252.83 / $9,442.98 / $22,101.07
| Facility | | $6,252.83 | $9,442.98 | $22,101.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,246.10 / $5,351.02 / $5,351.02
| Professional | | $5,246.10 | $5,351.02 | $5,351.02 |
- 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 / $5,351.02
| Professional | | $5,351.02 | $5,351.02 | $5,351.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,614.29 / $8,690.06 / $16,515.91
| Professional | | $5,614.29 | $8,690.06 | $16,515.91 |
- 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 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,096.22 / $5,605.84 / $7,134.71
| Professional | | $5,096.22 | $5,605.84 | $7,134.71 |