- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,467.37 / $4,073.80
| Professional | | $3,311.31 | $3,467.37 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,754.40 / $6,165.95
| Facility | | $5,128.61 | $5,754.40 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $6,606.93
| Professional | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $6,025.60
| Facility | | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $7,244.36
| Professional | | $2,089.30 | $3,019.95 | $7,244.36 |