- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $5,011.87
| Professional | | $3,981.07 | $3,981.07 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $3,019.95 / $6,456.54
| Facility | | $54.95 | $3,019.95 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,162.28 / $13,489.63
| Professional | | $2,511.89 | $3,162.28 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.96 / $3,235.94 / $3,890.45
| Professional | | $10.96 | $3,235.94 | $3,890.45 |