- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.61 / $1,434.13 / $1,589.17
| Professional | | $1,356.61 | $1,434.13 | $1,589.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,453.51 / $3,789.64 / $4,415.56
| Facility | | $1,453.51 | $3,789.64 | $4,415.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.48 / $1,453.51 / $1,453.51
| Professional | | $1,235.48 | $1,453.51 | $1,453.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,730.00 / $5,730.00 / $5,730.00
| Facility | | $5,730.00 | $5,730.00 | $5,730.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.96 / $1,162.81 / $2,795.19
| Professional | | $813.96 | $1,162.81 | $2,795.19 |