- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.53 / $8,812.58 / $8,812.58
| Professional | | $1,203.53 | $8,812.58 | $8,812.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,638.80 / $2,757.77 / $2,757.77
| Facility | | $1,638.80 | $2,757.77 | $2,757.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,638.80 / $2,757.77 / $2,757.77
| Professional | | $1,638.80 | $2,757.77 | $2,757.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,356.74 / $2,626.45 / $2,757.77
| Facility | | $1,356.74 | $2,626.45 | $2,757.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,069.83 / $2,115.69 / $2,907.19
| Professional | | $2,069.83 | $2,115.69 | $2,907.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,376.73 / $1,376.73 / $1,517.57
| Facility | | $1,376.73 | $1,376.73 | $1,517.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,097.29 / $1,214.06 / $1,857.84
| Professional | | $1,097.29 | $1,214.06 | $1,857.84 |