- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,663.77 / $1,956.80 / $10,299.20
| Professional | | $1,663.77 | $1,956.80 | $10,299.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.60 / $3,140.60 / $3,140.60
| Facility | | $3,140.60 | $3,140.60 | $3,140.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.08 / $3,135.12 / $5,663.62
| Professional | | $1,867.08 | $3,135.12 | $5,663.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,934.35 / $2,605.14 / $3,605.25
| Facility | | $1,934.35 | $2,605.14 | $3,605.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,974.41 / $3,215.79 / $5,358.65
| Professional | | $1,974.41 | $3,215.79 | $5,358.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,742.44 / $3,352.31 / $4,211.66
| Professional | | $2,742.44 | $3,352.31 | $4,211.66 |