- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.80 / $1,704.92 / $6,218.68
| Professional | | $1,306.80 | $1,704.92 | $6,218.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,941.78 / $1,941.78 / $1,941.78
| Facility | | $1,941.78 | $1,941.78 | $1,941.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.30 / $1,517.27 / $1,941.78
| Professional | | $845.30 | $1,517.27 | $1,941.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $957.62 / $1,197.02 / $1,761.51
| Facility | | $957.62 | $1,197.02 | $1,761.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.72 / $1,834.96 / $2,554.30
| Professional | | $1,133.72 | $1,834.96 | $2,554.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.34 / $1,885.94 / $2,173.29
| Professional | | $1,604.34 | $1,885.94 | $2,173.29 |