- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,064.28 / $8,623.17 / $8,623.17
| Professional | | $2,064.28 | $8,623.17 | $8,623.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,558.54 / $2,558.54 / $2,558.54
| Facility | | $2,558.54 | $2,558.54 | $2,558.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.69 / $2,558.54 / $2,742.97
| Professional | | $1,883.69 | $2,558.54 | $2,742.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,264.58 / $3,001.05 / $3,085.34
| Facility | | $1,264.58 | $3,001.05 | $3,085.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.27 / $2,322.65 / $3,350.20
| Professional | | $1,548.27 | $2,322.65 | $3,350.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,354.67 / $2,844.01 / $4,454.80
| Professional | | $2,354.67 | $2,844.01 | $4,454.80 |