- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.83 / $6,697.50 / $6,697.50
| Professional | | $1,488.83 | $6,697.50 | $6,697.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,047.47 / $2,047.47 / $2,047.47
| Facility | | $2,047.47 | $2,047.47 | $2,047.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,655.03 / $2,047.47 / $2,047.47
| Professional | | $1,655.03 | $2,047.47 | $2,047.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,047.47 / $2,645.50 / $2,800.08
| Facility | | $2,047.47 | $2,645.50 | $2,800.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,259.39 / $1,784.16 / $2,725.10
| Professional | | $1,259.39 | $1,784.16 | $2,725.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.69 / $2,392.59 / $3,587.16
| Professional | | $2,006.69 | $2,392.59 | $3,587.16 |