- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,685.60 / $8,264.51 / $8,264.51
| Professional | | $1,685.60 | $8,264.51 | $8,264.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,651.08 / $2,651.08 / $2,651.08
| Facility | | $2,651.08 | $2,651.08 | $2,651.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,679.30 / $2,651.08 / $2,844.82
| Professional | | $1,679.30 | $2,651.08 | $2,844.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,305.30 / $2,787.20 / $2,994.26
| Facility | | $1,305.30 | $2,787.20 | $2,994.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.33 / $2,385.73 / $3,441.20
| Professional | | $1,590.33 | $2,385.73 | $3,441.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,233.90 / $2,787.20 / $4,621.28
| Professional | | $2,233.90 | $2,787.20 | $4,621.28 |