- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,577.98 / $5,278.00 / $7,751.67
| Professional | | $1,577.98 | $5,278.00 | $7,751.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,411.84 / $2,411.84 / $2,411.84
| Facility | | $2,411.84 | $2,411.84 | $2,411.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.66 / $2,411.84 / $2,531.69
| Professional | | $1,588.66 | $2,411.84 | $2,531.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,186.43 / $2,499.90 / $2,645.12
| Facility | | $1,186.43 | $2,499.90 | $2,645.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.10 / $2,182.88 / $3,148.60
| Professional | | $1,455.10 | $2,182.88 | $3,148.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,013.48 / $2,499.89 / $4,193.96
| Professional | | $2,013.48 | $2,499.89 | $4,193.96 |