- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,073.80 / $5,248.07
| Professional | | $2,818.38 | $4,073.80 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Professional | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,466.84
| Facility | | $4,265.80 | $4,265.80 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $4,265.80 / $6,760.83
| Professional | | $457.09 | $4,265.80 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $602.56 / $3,467.37
| Facility | | $257.04 | $602.56 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,398.83 / $4,265.80
| Professional | | $1,479.11 | $2,398.83 | $4,265.80 |