- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,378.42 / $4,378.42 / $4,378.42
| Professional | | $4,378.42 | $4,378.42 | $4,378.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,682.98 / $2,509.71 / $6,395.32
| Facility | | $1,682.98 | $2,509.71 | $6,395.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,849.76 / $4,483.93 / $4,483.93
| Professional | | $1,849.76 | $4,483.93 | $4,483.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,682.98 / $2,509.71 / $6,395.32
| Facility | | $1,682.98 | $2,509.71 | $6,395.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.29 / $1,466.09 / $4,483.93
| Professional | | $977.29 | $1,466.09 | $4,483.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,275.21 / $5,275.21 / $5,275.21
| Professional | | $5,275.21 | $5,275.21 | $5,275.21 |