- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,030.07 / $2,833.26 / $4,712.09
| Professional | | $2,030.07 | $2,833.26 | $4,712.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $2,673.00
| Facility | | $2,673.00 | $2,673.00 | $2,673.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.05 / $2,673.00 / $5,756.25
| Professional | | $2,272.05 | $2,673.00 | $5,756.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $361.08 / $3,571.84 / $3,571.84
| Professional | | $361.08 | $3,571.84 | $3,571.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,744.37 / $2,229.42 / $4,013.55
| Professional | | $1,744.37 | $2,229.42 | $4,013.55 |