- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,327.29 / $2,686.82 / $3,340.79
| Professional | | $2,327.29 | $2,686.82 | $3,340.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $670.20 / $670.20 / $670.20
| Facility | | $670.20 | $670.20 | $670.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.62 / $401.62 / $401.62
| Professional | | $401.62 | $401.62 | $401.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,434.80 / $2,671.66 / $2,671.66
| Facility | | $2,434.80 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.64 / $2,671.66 / $2,671.66
| Professional | | $286.64 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.55 / $1,552.10 / $3,468.71
| Professional | | $907.55 | $1,552.10 | $3,468.71 |