- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,897.79 / $7,413.10
| Professional | | $3,235.94 | $4,897.79 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,786.30 / $4,786.30
| Professional | | $4,073.80 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $3,388.44 / $5,128.61
| Facility | | $446.68 | $3,388.44 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,073.80 / $6,760.83
| Professional | | $2,570.40 | $4,073.80 | $6,760.83 |