- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,904.11 / $6,604.31 / $6,604.31
| Professional | | $1,904.11 | $6,604.31 | $6,604.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,473.53 / $1,802.59 / $1,802.59
| Facility | | $1,473.53 | $1,802.59 | $1,802.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.53 / $1,517.74 / $1,802.59
| Professional | | $1,473.53 | $1,517.74 | $1,802.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $957.13 / $1,716.75 / $1,802.59
| Facility | | $957.13 | $1,716.75 | $1,802.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.93 / $1,473.53 / $1,835.50
| Professional | | $1,352.93 | $1,473.53 | $1,835.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.09 / $856.46 / $1,319.79
| Professional | | $774.09 | $856.46 | $1,319.79 |