- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.22 / $6,140.54 / $6,140.54
| Professional | | $1,364.22 | $6,140.54 | $6,140.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,878.68 / $1,878.68 / $2,254.42
| Professional | | $1,878.68 | $1,878.68 | $2,254.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,878.68 / $1,878.68 / $1,878.68
| Facility | | $1,878.68 | $1,878.68 | $1,878.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,521.98 / $1,878.68 / $1,878.68
| Professional | | $1,521.98 | $1,878.68 | $1,878.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,878.68 / $2,401.75 / $2,480.67
| Facility | | $1,878.68 | $2,401.75 | $2,480.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.57 / $1,635.67 / $2,498.30
| Professional | | $1,154.57 | $1,635.67 | $2,498.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,837.69 / $2,085.07 / $3,287.44
| Professional | | $1,837.69 | $2,085.07 | $3,287.44 |