- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $13,182.57
| Professional | | $2,041.74 | $2,454.71 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Professional | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.17 / $3,467.37 / $4,265.80
| Facility | | $4.17 | $3,467.37 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,951.21 / $4,168.69
| Professional | | $2,511.89 | $2,951.21 | $4,168.69 |