- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.26 / $6,066.94 / $6,066.94
| Professional | | $1,323.26 | $6,066.94 | $6,066.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,837.67 / $1,837.67 / $1,837.67
| Facility | | $1,837.67 | $1,837.67 | $1,837.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,402.22 / $1,837.67 / $1,837.67
| Professional | | $1,402.22 | $1,837.67 | $1,837.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,837.67 / $2,180.10 / $2,271.31
| Facility | | $1,837.67 | $2,180.10 | $2,271.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.63 / $1,601.76 / $2,446.50
| Professional | | $1,130.63 | $1,601.76 | $2,446.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.54 / $2,060.41 / $3,225.48
| Professional | | $1,710.54 | $2,060.41 | $3,225.48 |