- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.13 / $5,174.12 / $5,174.12
| Professional | | $1,149.13 | $5,174.12 | $5,174.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,581.61 / $1,581.61 / $1,581.61
| Facility | | $1,581.61 | $1,581.61 | $1,581.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.60 / $1,581.61 / $1,581.61
| Professional | | $1,284.60 | $1,581.61 | $1,581.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,581.61 / $2,013.70 / $2,066.38
| Facility | | $1,581.61 | $2,013.70 | $2,066.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.76 / $1,378.11 / $2,104.90
| Professional | | $972.76 | $1,378.11 | $2,104.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.05 / $1,803.80 / $2,770.37
| Professional | | $1,548.05 | $1,803.80 | $2,770.37 |