- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.62 / $9,608.51 / $9,608.51
| Professional | | $1,960.62 | $9,608.51 | $9,608.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,074.35 / $3,074.35 / $3,074.35
| Facility | | $3,074.35 | $3,074.35 | $3,074.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,956.51 / $3,074.35 / $3,330.20
| Professional | | $1,956.51 | $3,074.35 | $3,330.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,512.76 / $3,265.60 / $3,501.52
| Facility | | $1,512.76 | $3,265.60 | $3,501.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,845.57 / $2,768.64 / $3,993.50
| Professional | | $1,845.57 | $2,768.64 | $3,993.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,607.55 / $3,265.59 / $5,359.43
| Professional | | $2,607.55 | $3,265.59 | $5,359.43 |