- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.85 / $1,853.72 / $6,902.68
| Professional | | $1,448.85 | $1,853.72 | $6,902.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,254.63 / $2,254.63 / $2,254.63
| Facility | | $2,254.63 | $2,254.63 | $2,254.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.99 / $2,245.36 / $2,254.63
| Professional | | $1,042.99 | $2,245.36 | $2,254.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,074.44 / $1,394.88 / $2,254.63
| Facility | | $1,074.44 | $1,394.88 | $2,254.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,293.68 / $2,156.26 / $2,799.30
| Professional | | $1,293.68 | $2,156.26 | $2,799.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,817.96 / $2,179.52 / $2,475.52
| Professional | | $1,817.96 | $2,179.52 | $2,475.52 |