- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,193.89 / $5,452.12 / $20,550.59
| Professional | | $4,193.89 | $5,452.12 | $20,550.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,185.51 / $6,185.51 / $6,185.51
| Facility | | $6,185.51 | $6,185.51 | $6,185.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,356.46 / $6,185.51 / $6,665.65
| Professional | | $3,356.46 | $6,185.51 | $6,665.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,057.29 / $4,203.77 / $6,185.51
| Facility | | $3,057.29 | $4,203.77 | $6,185.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,762.31 / $6,185.51 / $8,141.00
| Professional | | $3,762.31 | $6,185.51 | $8,141.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,619.19 / $6,642.15 / $7,652.02
| Professional | | $5,619.19 | $6,642.15 | $7,652.02 |