- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.35 / $9,260.66 / $9,260.66
| Professional | | $1,830.35 | $9,260.66 | $9,260.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,745.73 / $2,745.73 / $2,745.73
| Facility | | $2,745.73 | $2,745.73 | $2,745.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.07 / $2,745.73 / $2,946.67
| Professional | | $2,032.07 | $2,745.73 | $2,946.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,357.58 / $3,303.30 / $3,376.29
| Facility | | $1,357.58 | $3,303.30 | $3,376.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,661.17 / $2,492.02 / $3,594.50
| Professional | | $1,661.17 | $2,492.02 | $3,594.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,591.82 / $3,004.28 / $4,782.25
| Professional | | $2,591.82 | $3,004.28 | $4,782.25 |