- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,783.74 / $20,060.59 / $20,060.59
| Professional | | $5,783.74 | $20,060.59 | $20,060.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.37 / $6,578.68 / $6,578.68
| Facility | | $3,745.37 | $6,578.68 | $6,578.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,745.37 / $6,578.68 / $6,578.68
| Professional | | $3,745.37 | $6,578.68 | $6,578.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,907.28 / $6,265.41 / $6,578.68
| Facility | | $2,907.28 | $6,265.41 | $6,578.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,937.59 / $5,047.02 / $6,617.82
| Professional | | $4,937.59 | $5,047.02 | $6,617.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,351.30 / $2,601.52 / $4,125.99
| Professional | | $2,351.30 | $2,601.52 | $4,125.99 |