- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,039.58 / $10,542.60 / $10,542.60
| Professional | | $3,039.58 | $10,542.60 | $10,542.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,696.10 / $3,696.10 / $3,696.10
| Professional | | $3,696.10 | $3,696.10 | $3,696.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,264.80 / $3,974.05 / $3,974.05
| Facility | | $2,264.80 | $3,974.05 | $3,974.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.80 / $3,231.74 / $3,974.05
| Professional | | $2,264.80 | $3,231.74 | $3,974.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,864.57 / $3,784.81 / $3,974.05
| Facility | | $1,864.57 | $3,784.81 | $3,974.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,264.80 / $2,982.70 / $3,976.93
| Professional | | $2,264.80 | $2,982.70 | $3,976.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.99 / $1,668.47 / $2,571.06
| Professional | | $1,507.99 | $1,668.47 | $2,571.06 |