- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $5,248.07
| Professional | | $2,630.27 | $2,630.27 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $4,073.80
| Professional | | $2,187.76 | $2,187.76 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $398.11 / $3,715.35
| Facility | | $281.84 | $398.11 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $3,715.35
| Professional | | $1,862.09 | $2,290.87 | $3,715.35 |