- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.25 / $5,064.31 / $5,064.31
| Professional | | $1,112.25 | $5,064.31 | $5,064.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.38 / $1,546.38 / $1,546.38
| Professional | | $1,546.38 | $1,546.38 | $1,546.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,546.38 / $1,546.38 / $1,546.38
| Facility | | $1,546.38 | $1,546.38 | $1,546.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.50 / $1,546.38 / $1,685.47
| Professional | | $1,096.50 | $1,546.38 | $1,685.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $762.60 / $1,789.45 / $1,865.88
| Facility | | $762.60 | $1,789.45 | $1,865.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.68 / $1,414.16 / $2,039.80
| Professional | | $942.68 | $1,414.16 | $2,039.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.03 / $1,686.81 / $2,701.93
| Professional | | $1,404.03 | $1,686.81 | $2,701.93 |