- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.02 / $6,530.82 / $6,530.82
| Professional | | $1,292.02 | $6,530.82 | $6,530.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,941.78 / $1,941.78 / $1,941.78
| Facility | | $1,941.78 | $1,941.78 | $1,941.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,397.28 / $1,941.78 / $2,089.38
| Professional | | $1,397.28 | $1,941.78 | $2,089.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.29 / $2,233.40 / $2,348.46
| Facility | | $960.29 | $2,233.40 | $2,348.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.33 / $1,760.18 / $2,538.90
| Professional | | $1,173.33 | $1,760.18 | $2,538.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.36 / $2,151.60 / $3,379.02
| Professional | | $1,752.36 | $2,151.60 | $3,379.02 |