- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,383.25 / $6,281.77 / $6,281.77
| Professional | | $1,383.25 | $6,281.77 | $6,281.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,913.91 / $1,913.91 / $1,913.91
| Facility | | $1,913.91 | $1,913.91 | $1,913.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,339.04 / $1,913.91 / $2,096.36
| Professional | | $1,339.04 | $1,913.91 | $2,096.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $942.81 / $2,233.40 / $2,296.61
| Facility | | $942.81 | $2,233.40 | $2,296.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.09 / $1,755.33 / $2,531.90
| Professional | | $1,170.09 | $1,755.33 | $2,531.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.36 / $2,099.81 / $3,352.19
| Professional | | $1,752.36 | $2,099.81 | $3,352.19 |