- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.53 / $1,955.25 / $7,101.48
| Professional | | $1,475.53 | $1,955.25 | $7,101.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,192.06 / $2,192.06 / $2,192.06
| Facility | | $2,192.06 | $2,192.06 | $2,192.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.77 / $2,191.81 / $2,192.06
| Professional | | $1,062.77 | $2,191.81 | $2,192.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.69 / $1,483.20 / $2,192.06
| Facility | | $1,078.69 | $1,483.20 | $2,192.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,337.35 / $2,191.81 / $2,893.80
| Professional | | $1,337.35 | $2,191.81 | $2,893.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.88 / $2,176.84 / $2,805.60
| Professional | | $1,826.88 | $2,176.84 | $2,805.60 |