- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,388.44 / $3,548.13
| Professional | | $2,951.21 | $3,388.44 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,691.53
| Professional | | $2,290.87 | $2,290.87 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $398.11 / $2,884.03
| Facility | | $263.03 | $398.11 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $3,981.07
| Professional | | $1,778.28 | $2,398.83 | $3,981.07 |