- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,801.89 / $4,897.79
| Professional | | $2,630.27 | $3,801.89 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $6,309.57
| Facility | | $3,467.37 | $3,467.37 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $3,467.37 / $7,413.10
| Professional | | $501.19 | $3,467.37 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $2,187.76 / $4,897.79
| Facility | | $288.40 | $2,187.76 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,090.30 / $4,897.79
| Professional | | $2,089.30 | $3,090.30 | $4,897.79 |