- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.72 / $5,983.12 / $5,983.12
| Professional | | $1,304.72 | $5,983.12 | $5,983.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,853.45 / $1,853.45 / $1,853.45
| Facility | | $1,853.45 | $1,853.45 | $1,853.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.86 / $1,853.45 / $2,539.27
| Professional | | $1,289.86 | $1,853.45 | $2,539.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $905.05 / $2,245.75 / $2,530.00
| Facility | | $905.05 | $2,245.75 | $2,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.46 / $1,704.86 / $2,539.27
| Professional | | $1,136.46 | $1,704.86 | $2,539.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.24 / $2,051.60 / $3,270.79
| Professional | | $1,683.24 | $2,051.60 | $3,270.79 |