- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.74 / $5,706.18 / $5,706.18
| Professional | | $1,365.74 | $5,706.18 | $5,706.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.86 / $1,698.86 / $1,698.86
| Facility | | $1,698.86 | $1,698.86 | $1,698.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.75 / $1,698.86 / $2,040.49
| Professional | | $1,266.75 | $1,698.86 | $2,040.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $840.44 / $1,972.75 / $2,034.12
| Facility | | $840.44 | $1,972.75 | $2,034.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.50 / $1,538.40 / $2,219.00
| Professional | | $1,025.50 | $1,538.40 | $2,219.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.09 / $1,877.99 / $2,955.38
| Professional | | $1,471.09 | $1,877.99 | $2,955.38 |