- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,942.03 / $4,631.53 / $22,996.80
| Professional | | $3,942.03 | $4,631.53 | $22,996.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,972.63 / $6,972.63 / $6,972.63
| Facility | | $6,972.63 | $6,972.63 | $6,972.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,838.16 / $6,972.63 / $12,908.73
| Professional | | $3,838.16 | $6,972.63 | $12,908.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,577.31 / $5,555.59 / $8,512.82
| Facility | | $2,577.31 | $5,555.59 | $8,512.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,606.47 / $7,129.84 / $11,880.87
| Professional | | $4,606.47 | $7,129.84 | $11,880.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,164.97 / $7,739.03 / $10,257.15
| Professional | | $6,164.97 | $7,739.03 | $10,257.15 |