- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,542.38 / $2,915.42 / $7,691.96
| Professional | | $2,542.38 | $2,915.42 | $7,691.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,889.41 / $4,889.41 / $4,889.41
| Facility | | $4,889.41 | $4,889.41 | $4,889.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,808.26 / $4,727.00 / $8,749.94
| Professional | | $2,808.26 | $4,727.00 | $8,749.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,864.23 / $3,907.49 / $5,357.30
| Facility | | $2,864.23 | $3,907.49 | $5,357.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,051.46 / $4,997.84 / $8,304.69
| Professional | | $3,051.46 | $4,997.84 | $8,304.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,179.20 / $5,032.10 / $6,156.16
| Professional | | $4,179.20 | $5,032.10 | $6,156.16 |