- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,938.86 / $2,961.45 / $3,673.58
| Professional | | $2,938.86 | $2,961.45 | $3,673.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.02 / $393.88 / $4,320.37
| Facility | | $320.02 | $393.88 | $4,320.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.02 / $344.65 / $4,652.71
| Professional | | $320.02 | $344.65 | $4,652.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,621.85 / $3,621.85 / $5,237.12
| Facility | | $3,621.85 | $3,621.85 | $5,237.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.96 / $3,621.85 / $3,621.85
| Professional | | $386.96 | $3,621.85 | $3,621.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,827.15 / $2,312.80 / $4,551.50
| Professional | | $1,827.15 | $2,312.80 | $4,551.50 |