- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,467.33 / $2,021.66 / $7,610.39
| Professional | | $1,467.33 | $2,021.66 | $7,610.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,210.46 / $2,210.46 / $2,210.46
| Facility | | $2,210.46 | $2,210.46 | $2,210.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.22 / $2,210.46 / $2,447.89
| Professional | | $1,239.22 | $2,210.46 | $2,447.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,095.20 / $1,505.90 / $2,210.46
| Facility | | $1,095.20 | $1,505.90 | $2,210.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,345.44 / $2,210.46 / $2,911.30
| Professional | | $1,345.44 | $2,210.46 | $2,911.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,929.82 / $2,340.42 / $2,627.84
| Professional | | $1,929.82 | $2,340.42 | $2,627.84 |