- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,570.40 / $3,467.37
| Professional | | $2,089.30 | $2,570.40 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,890.45
| Facility | | $2,818.38 | $2,818.38 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,818.38
| Professional | | $2,398.83 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $6,025.60
| Professional | | $4,168.69 | $5,128.61 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,818.38 / $3,548.13
| Facility | | $1,174.90 | $2,818.38 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,981.07 / $10,964.78
| Professional | | $1,819.70 | $3,981.07 | $10,964.78 |