- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,775.69 / $20,032.70 / $20,032.70
| Professional | | $5,775.69 | $20,032.70 | $20,032.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,423.18 / $7,297.77 / $7,297.77
| Facility | | $4,423.18 | $7,297.77 | $7,297.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,423.18 / $7,297.77 / $7,297.77
| Professional | | $4,423.18 | $7,297.77 | $7,297.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,624.10 / $6,950.26 / $7,297.77
| Facility | | $3,624.10 | $6,950.26 | $7,297.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,423.18 / $5,477.30 / $7,303.07
| Professional | | $4,423.18 | $5,477.30 | $7,303.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,931.04 / $3,242.96 / $5,143.31
| Professional | | $2,931.04 | $3,242.96 | $5,143.31 |