- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,983.87 / $2,595.69 / $4,679.30
| Professional | | $1,983.87 | $2,595.69 | $4,679.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,657.49 / $3,657.49 / $3,657.49
| Facility | | $3,657.49 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,108.87 / $3,657.49 / $5,767.50
| Professional | | $3,108.87 | $3,657.49 | $5,767.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,733.12 / $3,733.12 / $3,733.12
| Professional | | $3,733.12 | $3,733.12 | $3,733.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,679.90 / $2,326.23 / $3,422.02
| Professional | | $1,679.90 | $2,326.23 | $3,422.02 |