- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,951.21 / $4,365.16
| Professional | | $2,187.76 | $2,951.21 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $3,630.78 / $5,754.40
| Professional | | $389.05 | $3,630.78 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,715.35 / $3,715.35
| Professional | | $3,548.13 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $501.19 / $3,388.44
| Facility | | $251.19 | $501.19 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,290.87 / $3,715.35
| Professional | | $1,659.59 | $2,290.87 | $3,715.35 |