- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,896.38 / $1,896.38 / $2,370.46
| Professional | | $1,896.38 | $1,896.38 | $2,370.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,023.35 / $4,470.06 / $4,470.06
| Facility | | $3,023.35 | $4,470.06 | $4,470.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,166.74 / $5,166.74 / $5,166.74
| Professional | | $5,166.74 | $5,166.74 | $5,166.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,941.94 / $1,941.94 / $3,151.58
| Facility | | $1,941.94 | $1,941.94 | $3,151.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.94 / $2,974.64 / $4,049.20
| Professional | | $1,941.94 | $2,974.64 | $4,049.20 |