- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,224.64 / $2,722.41 / $10,174.79
| Professional | | $2,224.64 | $2,722.41 | $10,174.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,258.91 / $3,258.91 / $3,258.91
| Facility | | $3,258.91 | $3,258.91 | $3,258.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.24 / $3,258.91 / $3,439.62
| Professional | | $1,291.24 | $3,258.91 | $3,439.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,605.30 / $1,725.14 / $3,258.91
| Facility | | $1,605.30 | $1,725.14 | $3,258.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,876.73 / $3,254.61 / $4,225.20
| Professional | | $1,876.73 | $3,254.61 | $4,225.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,118.50 / $3,216.69 / $3,707.09
| Professional | | $2,118.50 | $3,216.69 | $3,707.09 |