- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,185.28 / $3,572.84 / $9,817.87
| Professional | | $2,185.28 | $3,572.84 | $9,817.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,000.74 / $3,000.74 / $3,000.74
| Facility | | $3,000.74 | $3,000.74 | $3,000.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,419.50 / $3,000.74 / $3,000.74
| Professional | | $2,419.50 | $3,000.74 | $3,000.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,000.74 / $3,849.95 / $3,989.81
| Facility | | $3,000.74 | $3,849.95 | $3,989.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,846.86 / $2,616.42 / $3,996.30
| Professional | | $1,846.86 | $2,616.42 | $3,996.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,945.28 / $3,413.74 / $5,255.84
| Professional | | $2,945.28 | $3,413.74 | $5,255.84 |