- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,773.75 / $5,536.20 / $6,883.73
| Professional | | $2,773.75 | $5,536.20 | $6,883.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,434.25 / $8,431.12 / $8,431.12
| Professional | | $5,434.25 | $8,431.12 | $8,431.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,704.40 / $3,704.40 / $5,351.58
| Facility | | $3,704.40 | $3,704.40 | $5,351.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $3,704.40 / $12,836.25
| Professional | | $782.55 | $3,704.40 | $12,836.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.24 / $6,011.15 / $9,227.00
| Facility | | $4,168.24 | $6,011.15 | $9,227.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,277.72 / $5,277.72 / $5,277.72
| Professional | | $5,277.72 | $5,277.72 | $5,277.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,894.20 / $3,130.20 / $4,715.39
| Professional | | $2,894.20 | $3,130.20 | $4,715.39 |