- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.02 / $5,707.98 / $5,707.98
| Professional | | $1,327.02 | $5,707.98 | $5,707.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,700.96 / $1,700.96 / $1,700.96
| Facility | | $1,700.96 | $1,700.96 | $1,700.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.88 / $1,076.01 / $1,739.02
| Professional | | $1,050.88 | $1,076.01 | $1,739.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $980.00 / $1,289.51 / $2,137.50
| Facility | | $980.00 | $1,289.51 | $2,137.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.76 / $1,456.02 / $2,020.96
| Professional | | $1,027.76 | $1,456.02 | $2,020.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.00 / $2,090.00 / $2,090.00
| Facility | | $2,090.00 | $2,090.00 | $2,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,568.28 / $1,740.78 / $2,137.81
| Professional | | $1,568.28 | $1,740.78 | $2,137.81 |