- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,875.53 / $3,631.10 / $3,631.10
| Professional | | $2,875.53 | $3,631.10 | $3,631.10 |
- 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
- $2,523.82 / $3,090.39 / $4,620.60
| Professional | | $2,523.82 | $3,090.39 | $4,620.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,988.02 / $3,631.10 / $5,056.30
| Professional | | $2,988.02 | $3,631.10 | $5,056.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,650.24 / $2,950.12 / $4,590.39
| Professional | | $2,650.24 | $2,950.12 | $4,590.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,875.53 / $3,631.10 / $3,631.10
| Professional | | $2,875.53 | $3,631.10 | $3,631.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,542.06 / $3,510.52 / $4,539.47
| Professional | | $2,542.06 | $3,510.52 | $4,539.47 |