- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.53 / $8,744.68 / $8,744.68
| Professional | | $1,910.53 | $8,744.68 | $8,744.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,655.82 / $2,655.82 / $2,655.82
| Facility | | $2,655.82 | $2,655.82 | $2,655.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,060.59 / $2,655.82 / $2,655.82
| Professional | | $2,060.59 | $2,655.82 | $2,655.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,655.82 / $3,211.00 / $3,313.67
| Facility | | $2,655.82 | $3,211.00 | $3,313.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,627.85 / $2,306.17 / $3,522.40
| Professional | | $1,627.85 | $2,306.17 | $3,522.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,519.40 / $2,984.41 / $4,656.43
| Professional | | $2,519.40 | $2,984.41 | $4,656.43 |