- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.65 / $2,480.65 / $3,100.82
| Professional | | $2,480.65 | $2,480.65 | $3,100.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,253.85 / $4,253.85 / $4,253.85
| Facility | | $4,253.85 | $4,253.85 | $4,253.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,974.00 / $5,897.00 / $5,897.00
| Professional | | $1,974.00 | $5,897.00 | $5,897.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,379.18 / $1,787.41 / $2,144.71
| Facility | | $1,379.18 | $1,787.41 | $2,144.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,379.18 / $2,245.86 / $2,443.21
| Professional | | $1,379.18 | $2,245.86 | $2,443.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.00 / $1,411.20 / $2,632.60
| Professional | | $6.00 | $1,411.20 | $2,632.60 |