- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,311.31 / $4,786.30
| Professional | | $1,737.80 | $3,311.31 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Professional | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $3,388.44
| Professional | | $1,479.11 | $1,479.11 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $190.55 / $1,148.15
| Facility | | $114.82 | $190.55 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $562.34 / $1,659.59
| Professional | | $181.97 | $562.34 | $1,659.59 |