- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,519.81 / $6,353.98 / $6,353.98
| Professional | | $1,519.81 | $6,353.98 | $6,353.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,887.10 / $1,887.10 / $1,887.10
| Facility | | $1,887.10 | $1,887.10 | $1,887.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.06 / $1,887.10 / $2,020.12
| Professional | | $1,320.06 | $1,887.10 | $2,020.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $932.90 / $2,239.25 / $2,295.98
| Facility | | $932.90 | $2,239.25 | $2,295.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.33 / $1,710.68 / $2,467.50
| Professional | | $1,140.33 | $1,710.68 | $2,467.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.95 / $2,094.60 / $3,284.66
| Professional | | $1,756.95 | $2,094.60 | $3,284.66 |