- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.97 / $5,758.37 / $5,758.37
| Professional | | $1,278.97 | $5,758.37 | $5,758.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,758.80 / $1,758.80 / $1,758.80
| Facility | | $1,758.80 | $1,758.80 | $1,758.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.70 / $1,758.80 / $1,758.80
| Professional | | $1,427.70 | $1,758.80 | $1,758.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,758.80 / $2,270.44 / $2,321.91
| Facility | | $1,758.80 | $2,270.44 | $2,321.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.78 / $1,532.56 / $2,340.80
| Professional | | $1,081.78 | $1,532.56 | $2,340.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,725.36 / $1,990.80 / $3,081.16
| Professional | | $1,725.36 | $1,990.80 | $3,081.16 |