- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.38 / $1,665.58 / $6,492.23
| Professional | | $1,230.38 | $1,665.58 | $6,492.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,964.39 / $1,964.39 / $1,964.39
| Facility | | $1,964.39 | $1,964.39 | $1,964.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.95 / $1,964.39 / $2,135.94
| Professional | | $1,065.95 | $1,964.39 | $2,135.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $972.34 / $1,336.96 / $1,964.39
| Facility | | $972.34 | $1,336.96 | $1,964.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.51 / $1,964.39 / $2,573.90
| Professional | | $1,189.51 | $1,964.39 | $2,573.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.98 / $2,053.71 / $2,305.92
| Professional | | $1,706.98 | $2,053.71 | $2,305.92 |