- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.52 / $8,222.53 / $8,222.53
| Professional | | $1,794.52 | $8,222.53 | $8,222.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,486.51 / $2,486.51 / $2,486.51
| Facility | | $2,486.51 | $2,486.51 | $2,486.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,839.03 / $2,486.51 / $2,486.51
| Professional | | $1,839.03 | $2,486.51 | $2,486.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,486.51 / $2,998.45 / $3,110.64
| Facility | | $2,486.51 | $2,998.45 | $3,110.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.45 / $2,169.59 / $3,313.80
| Professional | | $1,531.45 | $2,169.59 | $3,313.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,352.63 / $2,799.00 / $4,366.00
| Professional | | $2,352.63 | $2,799.00 | $4,366.00 |