- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,064.24 / $17,565.09 / $17,565.09
| Professional | | $5,064.24 | $17,565.09 | $17,565.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.06 / $6,392.30 / $6,392.30
| Facility | | $2,853.06 | $6,392.30 | $6,392.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,853.06 / $5,198.27 / $6,392.30
| Professional | | $2,853.06 | $5,198.27 | $6,392.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.61 / $6,087.90 / $6,392.30
| Facility | | $2,545.61 | $6,087.90 | $6,392.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,853.06 / $4,797.70 / $6,396.94
| Professional | | $2,853.06 | $4,797.70 | $6,396.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,058.79 / $2,277.89 / $3,510.16
| Professional | | $2,058.79 | $2,277.89 | $3,510.16 |