- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,388.44 / $3,388.44
| Professional | | $3,235.94 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $407.38 / $407.38
| Professional | | $263.03 | $407.38 | $407.38 |
- 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
- $3,090.30 / $3,630.78 / $3,630.78
| Professional | | $3,090.30 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $2,754.23
| Facility | | $316.23 | $316.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,089.30 / $3,467.37
| Professional | | $1,659.59 | $2,089.30 | $3,467.37 |