- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.64 / $1,396.94 / $5,267.65
| Professional | | $1,103.64 | $1,396.94 | $5,267.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,608.42 / $1,608.42 / $1,608.42
| Facility | | $1,608.42 | $1,608.42 | $1,608.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.26 / $1,608.42 / $1,737.27
| Professional | | $1,008.26 | $1,608.42 | $1,737.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $792.75 / $1,090.03 / $1,608.42
| Facility | | $792.75 | $1,090.03 | $1,608.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.50 / $1,608.42 / $2,123.80
| Professional | | $981.50 | $1,608.42 | $2,123.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.03 / $1,726.66 / $1,911.06
| Professional | | $1,455.03 | $1,726.66 | $1,911.06 |