- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,795.41 / $2,795.41 / $3,494.26
| Professional | | $2,795.41 | $2,795.41 | $3,494.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,847.70 / $1,863.26 / $11,632.60
| Facility | | $1,847.70 | $1,863.26 | $11,632.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,205.00 / $8,064.84 / $8,064.84
| Professional | | $2,205.00 | $8,064.84 | $8,064.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,205.00 / $2,205.00 / $2,205.00
| Facility | | $2,205.00 | $2,205.00 | $2,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,788.00 / $2,341.30 / $2,666.02
| Professional | | $1,788.00 | $2,341.30 | $2,666.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.00 / $1,973.10 / $2,558.10
| Professional | | $11.00 | $1,973.10 | $2,558.10 |