- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,251.00 / $3,760.38 / $4,700.47
| Professional | | $2,251.00 | $3,760.38 | $4,700.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,106.14 / $5,106.14 / $5,106.14
| Facility | | $5,106.14 | $5,106.14 | $5,106.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.27 / $5,106.14 / $8,298.75
| Professional | | $560.27 | $5,106.14 | $8,298.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.27 / $2,251.00 / $33,203.46
| Facility | | $477.27 | $2,251.00 | $33,203.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.30 / $3,131.23 / $4,916.18
| Professional | | $1,743.30 | $3,131.23 | $4,916.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,743.30 / $3,072.61 / $4,502.00
| Professional | | $1,743.30 | $3,072.61 | $4,502.00 |