- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.55 / $1,918.92 / $11,997.70
| Professional | | $1,835.55 | $1,918.92 | $11,997.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,842.55 / $3,842.55 / $3,842.55
| Facility | | $3,842.55 | $3,842.55 | $3,842.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,539.30 / $3,842.55 / $4,137.43
| Professional | | $2,539.30 | $3,842.55 | $4,137.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,892.19 / $3,825.36 / $3,842.55
| Facility | | $1,892.19 | $3,825.36 | $3,842.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,306.56 / $3,460.19 / $4,991.00
| Professional | | $2,306.56 | $3,460.19 | $4,991.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,250.50 / $4,012.44 / $6,700.69
| Professional | | $3,250.50 | $4,012.44 | $6,700.69 |