- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.88 / $1,955.97 / $7,347.29
| Professional | | $1,399.88 | $1,955.97 | $7,347.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,100.05 / $2,100.05 / $2,100.05
| Facility | | $2,100.05 | $2,100.05 | $2,100.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.13 / $2,100.05 / $2,252.34
| Professional | | $1,131.13 | $2,100.05 | $2,252.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,038.10 / $1,427.40 / $2,100.05
| Facility | | $1,038.10 | $1,427.40 | $2,100.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.61 / $2,100.05 / $2,779.70
| Professional | | $1,284.61 | $2,100.05 | $2,779.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,653.74 / $1,653.74 / $11,831.32
| Facility | | $1,653.74 | $1,653.74 | $11,831.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,858.37 / $2,214.23 / $2,530.55
| Professional | | $1,858.37 | $2,214.23 | $2,530.55 |