- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.65 / $5,565.85 / $5,565.85
| Professional | | $1,392.65 | $5,565.85 | $5,565.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,704.64 / $1,704.64 / $1,704.64
| Facility | | $1,704.64 | $1,704.64 | $1,704.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.16 / $1,704.64 / $1,880.44
| Professional | | $1,195.16 | $1,704.64 | $1,880.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $834.42 / $1,871.35 / $1,989.85
| Facility | | $834.42 | $1,871.35 | $1,989.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.38 / $1,560.72 / $2,251.19
| Professional | | $1,040.38 | $1,560.72 | $2,251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,468.29 / $1,813.06 / $2,991.44
| Professional | | $1,468.29 | $1,813.06 | $2,991.44 |