- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,629.78 / $7,985.18 / $7,985.18
| Professional | | $1,629.78 | $7,985.18 | $7,985.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,562.21 / $2,562.21 / $2,562.21
| Facility | | $2,562.21 | $2,562.21 | $2,562.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.65 / $2,562.21 / $2,750.53
| Professional | | $1,551.65 | $2,562.21 | $2,750.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.70 / $2,607.80 / $2,755.17
| Facility | | $1,261.70 | $2,607.80 | $2,755.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,537.27 / $2,306.15 / $3,326.40
| Professional | | $1,537.27 | $2,306.15 | $3,326.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,159.65 / $2,665.10 / $4,465.88
| Professional | | $2,159.65 | $2,665.10 | $4,465.88 |