- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,019.95
| Professional | | $2,454.71 | $2,454.71 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $2,089.30 / $4,073.80
| Facility | | $54.95 | $2,089.30 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,238.72 / $8,317.64
| Professional | | $1,513.56 | $2,238.72 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.96 / $2,290.87 / $2,754.23
| Professional | | $10.96 | $2,290.87 | $2,754.23 |