- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,843.83 / $3,470.64 / $3,470.64
| Professional | | $2,843.83 | $3,470.64 | $3,470.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,010.53 / $14,279.49 / $16,101.93
| Facility | | $11,010.53 | $14,279.49 | $16,101.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,412.64 / $2,955.67 / $4,412.20
| Professional | | $2,412.64 | $2,955.67 | $4,412.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,856.33 / $3,470.64 / $4,834.74
| Professional | | $2,856.33 | $3,470.64 | $4,834.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,534.69 / $2,821.51 / $4,390.27
| Professional | | $2,534.69 | $2,821.51 | $4,390.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,843.83 / $3,470.64 / $3,470.64
| Professional | | $2,843.83 | $3,470.64 | $3,470.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,425.73 / $3,360.30 / $4,055.54
| Professional | | $2,425.73 | $3,360.30 | $4,055.54 |