- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,528.19 / $4,625.55 / $17,186.59
| Professional | | $3,528.19 | $4,625.55 | $17,186.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,196.47 / $5,196.47 / $5,196.47
| Facility | | $5,196.47 | $5,196.47 | $5,196.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,477.41 / $5,196.47 / $5,520.27
| Professional | | $2,477.41 | $5,196.47 | $5,520.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,559.82 / $3,519.75 / $5,196.47
| Facility | | $2,559.82 | $3,519.75 | $5,196.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,176.77 / $5,196.47 / $6,874.00
| Professional | | $3,176.77 | $5,196.47 | $6,874.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,320.57 / $5,330.07 / $6,032.50
| Professional | | $4,320.57 | $5,330.07 | $6,032.50 |