- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.06 / $4,867.05 / $4,867.05
| Professional | | $1,081.06 | $4,867.05 | $4,867.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,488.01 / $1,488.01 / $1,488.01
| Facility | | $1,488.01 | $1,488.01 | $1,488.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.48 / $1,488.01 / $1,488.01
| Professional | | $1,220.48 | $1,488.01 | $1,488.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,488.01 / $1,926.60 / $1,989.21
| Facility | | $1,488.01 | $1,926.60 | $1,989.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.18 / $1,296.53 / $1,980.30
| Professional | | $915.18 | $1,296.53 | $1,980.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.48 / $1,735.39 / $2,605.71
| Professional | | $1,455.48 | $1,735.39 | $2,605.71 |