- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,630.78 / $4,677.35
| Professional | | $2,398.83 | $3,630.78 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $4,168.69
| Professional | | $4,168.69 | $4,168.69 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $6,309.57
| Facility | | $3,467.37 | $3,467.37 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $3,467.37 / $7,413.10
| Professional | | $501.19 | $3,467.37 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $2,187.76 / $3,801.89
| Facility | | $281.84 | $2,187.76 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,388.44 / $4,897.79
| Professional | | $2,089.30 | $3,388.44 | $4,897.79 |