- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.56 / $6,731.81 / $6,731.81
| Professional | | $1,426.56 | $6,731.81 | $6,731.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,031.17 / $2,031.17 / $2,031.17
| Facility | | $2,031.17 | $2,031.17 | $2,031.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.85 / $2,031.17 / $2,035.25
| Professional | | $1,314.85 | $2,031.17 | $2,035.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $996.35 / $2,059.19 / $2,257.39
| Facility | | $996.35 | $2,059.19 | $2,257.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.18 / $1,866.46 / $2,692.20
| Professional | | $1,244.18 | $1,866.46 | $2,692.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,704.68 / $2,139.92 / $3,582.52
| Professional | | $1,704.68 | $2,139.92 | $3,582.52 |