- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.82 / $9,055.93 / $9,055.93
| Professional | | $1,975.82 | $9,055.93 | $9,055.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,758.35 / $2,758.35 / $2,758.35
| Facility | | $2,758.35 | $2,758.35 | $2,758.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.91 / $2,758.35 / $2,758.35
| Professional | | $2,035.91 | $2,758.35 | $2,758.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,758.35 / $3,255.20 / $3,376.29
| Facility | | $2,758.35 | $3,255.20 | $3,376.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,686.41 / $2,389.12 / $3,649.10
| Professional | | $1,686.41 | $2,389.12 | $3,649.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.07 / $3,081.60 / $4,829.42
| Professional | | $2,554.07 | $3,081.60 | $4,829.42 |