- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,570.40 / $2,630.27
| Professional | | $2,041.74 | $2,570.40 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Facility | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Professional | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,548.13 / $8,128.31
| Facility | | $2,691.53 | $3,548.13 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,548.13 / $8,128.31
| Professional | | $2,691.53 | $3,548.13 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,890.45 / $6,025.60
| Facility | | $2,398.83 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $2,454.71 / $3,890.45
| Professional | | $79.43 | $2,454.71 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $2,691.53
| Professional | | $1,148.15 | $1,148.15 | $2,691.53 |