- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,570.72 / $4,787.06 / $5,029.47
| Professional | | $3,570.72 | $4,787.06 | $5,029.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,864.68 / $4,864.68 / $4,864.68
| Professional | | $4,864.68 | $4,864.68 | $4,864.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,070.56 / $4,424.52 / $4,424.52
| Professional | | $4,070.56 | $4,424.52 | $4,424.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.00 / $2,900.00 / $6,630.73
| Facility | | $2,900.00 | $2,900.00 | $6,630.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.34 / $2,900.00 / $7,878.75
| Professional | | $480.34 | $2,900.00 | $7,878.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.57 / $2,687.49 / $4,190.58
| Professional | | $1,860.57 | $2,687.49 | $4,190.58 |