- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,063.15 / $15,145.10 / $15,145.10
| Professional | | $3,063.15 | $15,145.10 | $15,145.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,619.14 / $4,619.14 / $4,619.14
| Facility | | $4,619.14 | $4,619.14 | $4,619.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,985.76 / $4,619.14 / $4,867.85
| Professional | | $2,985.76 | $4,619.14 | $4,867.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.71 / $4,894.50 / $5,159.30
| Facility | | $2,282.71 | $4,894.50 | $5,159.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,821.24 / $4,232.30 / $6,104.70
| Professional | | $2,821.24 | $4,232.30 | $6,104.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,939.06 / $4,944.79 / $8,101.13
| Professional | | $3,939.06 | $4,944.79 | $8,101.13 |