- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,870.50 / $5,370.42 / $7,394.96
| Professional | | $2,870.50 | $5,370.42 | $7,394.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,608.68 / $7,608.68 / $7,608.68
| Facility | | $7,608.68 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,467.38 / $7,608.68 / $7,608.68
| Professional | | $6,467.38 | $7,608.68 | $7,608.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,524.87 / $5,524.87 / $7,028.03
| Professional | | $5,524.87 | $5,524.87 | $7,028.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,911.41 / $4,234.78 / $5,293.48
| Professional | | $2,911.41 | $4,234.78 | $5,293.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,546.67 / $3,493.60 / $5,315.75
| Professional | | $2,546.67 | $3,493.60 | $5,315.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,662.05 / $4,662.05 / $4,662.05
| Professional | | $4,662.05 | $4,662.05 | $4,662.05 |