- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,391.01 / $4,761.22 / $6,376.65
| Professional | | $4,391.01 | $4,761.22 | $6,376.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Facility | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,649.60 / $5,470.13 / $5,470.13
| Professional | | $4,649.60 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Facility | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,470.13 / $5,470.13 / $5,470.13
| Professional | | $5,470.13 | $5,470.13 | $5,470.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.59 / $4,948.56 / $5,673.70
| Professional | | $1,842.59 | $4,948.56 | $5,673.70 |