- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.49 / $4,749.67 / $4,749.67
| Professional | | $1,054.49 | $4,749.67 | $4,749.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,454.36 / $1,454.36 / $1,454.36
| Facility | | $1,454.36 | $1,454.36 | $1,454.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.13 / $1,454.36 / $1,454.36
| Professional | | $1,177.13 | $1,454.36 | $1,454.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,454.36 / $1,873.47 / $1,874.60
| Facility | | $1,454.36 | $1,873.47 | $1,874.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.83 / $1,266.28 / $1,934.10
| Professional | | $893.83 | $1,266.28 | $1,934.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,417.00 / $1,702.35 / $3,855.73
| Professional | | $1,417.00 | $1,702.35 | $3,855.73 |