- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,294.48 / $10,489.50 / $10,489.50
| Professional | | $2,294.48 | $10,489.50 | $10,489.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,181.62 / $3,181.62 / $3,181.62
| Facility | | $3,181.62 | $3,181.62 | $3,181.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,256.10 / $3,181.62 / $3,181.62
| Professional | | $2,256.10 | $3,181.62 | $3,181.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,181.62 / $3,818.10 / $3,957.55
| Facility | | $3,181.62 | $3,818.10 | $3,957.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,952.97 / $2,766.76 / $4,225.89
| Professional | | $1,952.97 | $2,766.76 | $4,225.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,995.74 / $3,588.01 / $5,582.36
| Professional | | $2,995.74 | $3,588.01 | $5,582.36 |