- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,972.00 / $10,308.20 / $10,308.20
| Professional | | $2,972.00 | $10,308.20 | $10,308.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,813.54 / $2,813.54
| Facility | | $2,283.76 | $2,813.54 | $2,813.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,283.76 / $2,813.54 / $2,813.54
| Professional | | $2,283.76 | $2,813.54 | $2,813.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,493.91 / $2,679.56 / $2,813.54
| Facility | | $1,493.91 | $2,679.56 | $2,813.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,111.67 / $2,283.76 / $3,123.05
| Professional | | $2,111.67 | $2,283.76 | $3,123.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.22 / $1,336.80 / $2,120.16
| Professional | | $1,208.22 | $1,336.80 | $2,120.16 |