- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.64 / $6,377.39 / $6,377.39
| Professional | | $1,298.64 | $6,377.39 | $6,377.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,044.84 / $2,044.84 / $2,044.84
| Facility | | $2,044.84 | $2,044.84 | $2,044.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.52 / $2,044.84 / $2,195.89
| Professional | | $1,246.52 | $2,044.84 | $2,195.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.15 / $2,086.50 / $2,261.82
| Facility | | $1,007.15 | $2,086.50 | $2,261.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,225.74 / $1,838.80 / $2,652.30
| Professional | | $1,225.74 | $1,838.80 | $2,652.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.54 / $2,162.34 / $3,562.18
| Professional | | $1,722.54 | $2,162.34 | $3,562.18 |