- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,387.16 / $6,819.66 / $6,819.66
| Professional | | $1,387.16 | $6,819.66 | $6,819.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,185.75 / $2,185.75 / $2,185.75
| Facility | | $2,185.75 | $2,185.75 | $2,185.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.50 / $2,185.75 / $2,348.94
| Professional | | $1,380.50 | $2,185.75 | $2,348.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,077.26 / $2,302.94 / $2,474.34
| Facility | | $1,077.26 | $2,302.94 | $2,474.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.53 / $1,964.49 / $2,833.60
| Professional | | $1,309.53 | $1,964.49 | $2,833.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.92 / $2,302.94 / $3,807.30
| Professional | | $1,841.92 | $2,302.94 | $3,807.30 |