- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.09 / $8,518.09 / $8,518.09
| Professional | | $1,894.09 | $8,518.09 | $8,518.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,601.13 / $2,601.13 / $2,601.13
| Facility | | $2,601.13 | $2,601.13 | $2,601.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,108.42 / $2,601.13 / $2,601.13
| Professional | | $2,108.42 | $2,601.13 | $2,601.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,601.13 / $3,306.55 / $3,392.73
| Facility | | $2,601.13 | $3,306.55 | $3,392.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.33 / $2,268.59 / $3,465.00
| Professional | | $1,601.33 | $2,268.59 | $3,465.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,554.23 / $2,947.20 / $4,558.39
| Professional | | $2,554.23 | $2,947.20 | $4,558.39 |