- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.46 / $6,768.27 / $6,768.27
| Professional | | $1,480.46 | $6,768.27 | $6,768.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,040.10 / $2,040.10 / $2,040.10
| Facility | | $2,040.10 | $2,040.10 | $2,040.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,557.29 / $2,040.10 / $2,040.10
| Professional | | $1,557.29 | $2,040.10 | $2,040.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,040.10 / $2,458.30 / $2,562.89
| Facility | | $2,040.10 | $2,458.30 | $2,562.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.35 / $1,785.54 / $2,727.20
| Professional | | $1,260.35 | $1,785.54 | $2,727.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,928.82 / $2,313.59 / $3,588.99
| Professional | | $1,928.82 | $2,313.59 | $3,588.99 |