- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.83 / $5,554.84 / $5,554.84
| Professional | | $1,120.83 | $5,554.84 | $5,554.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,706.22 / $1,706.22 / $1,706.22
| Facility | | $1,706.22 | $1,706.22 | $1,706.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.29 / $1,706.22 / $1,801.87
| Professional | | $1,091.29 | $1,706.22 | $1,801.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $838.66 / $1,801.15 / $1,918.37
| Facility | | $838.66 | $1,801.15 | $1,918.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.70 / $1,561.21 / $2,251.90
| Professional | | $1,040.70 | $1,561.21 | $2,251.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.32 / $1,773.44 / $2,996.08
| Professional | | $1,428.32 | $1,773.44 | $2,996.08 |