- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,925.31 / $3,814.67 / $14,325.00
| Professional | | $2,925.31 | $3,814.67 | $14,325.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,329.96 / $4,329.96 / $4,329.96
| Facility | | $4,329.96 | $4,329.96 | $4,329.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.41 / $3,532.16 / $4,329.96
| Professional | | $2,255.41 | $3,532.16 | $4,329.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,140.53 / $2,943.23 / $4,329.96
| Facility | | $2,140.53 | $2,943.23 | $4,329.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,628.11 / $4,067.56 / $5,686.80
| Professional | | $2,628.11 | $4,067.56 | $5,686.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,742.12 / $4,389.75 / $5,046.30
| Professional | | $3,742.12 | $4,389.75 | $5,046.30 |