- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,947.82 / $4,664.59 / $4,664.59
| Professional | | $2,947.82 | $4,664.59 | $4,664.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,428.68 / $4,925.20 / $4,925.20
| Professional | | $4,428.68 | $4,925.20 | $4,925.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,030.60 / $5,030.60 / $5,030.60
| Facility | | $5,030.60 | $5,030.60 | $5,030.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.50 / $2,163.84 / $5,156.35
| Professional | | $422.50 | $2,163.84 | $5,156.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,947.82 / $3,901.86 / $4,664.59
| Professional | | $2,947.82 | $3,901.86 | $4,664.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.08 / $3,383.93 / $7,540.82
| Professional | | $2,230.08 | $3,383.93 | $7,540.82 |