- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,981.07 / $5,754.40
| Professional | | $2,884.03 | $3,981.07 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Professional | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Facility | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Professional | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $2,570.40 / $4,570.88
| Facility | | $295.12 | $2,570.40 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,311.31 / $5,370.32
| Professional | | $2,884.03 | $3,311.31 | $5,370.32 |