- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.44 / $1,233.21 / $5,557.33
| Professional | | $1,167.44 | $1,233.21 | $5,557.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,697.28 / $1,697.28 / $1,697.28
| Facility | | $1,697.28 | $1,697.28 | $1,697.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.64 / $1,697.28 / $1,697.28
| Professional | | $1,334.64 | $1,697.28 | $1,697.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,697.28 / $2,184.65 / $2,315.58
| Facility | | $1,697.28 | $2,184.65 | $2,315.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.29 / $1,478.02 / $2,257.50
| Professional | | $1,043.29 | $1,478.02 | $2,257.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.04 / $1,921.20 / $2,972.03
| Professional | | $1,665.04 | $1,921.20 | $2,972.03 |