- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.27 / $1,430.63 / $2,563.46
| Professional | | $948.27 | $1,430.63 | $2,563.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,406.76
| Facility | | $1,406.76 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.75 / $1,406.76 / $3,588.75
| Professional | | $1,195.75 | $1,406.76 | $3,588.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,693.82 / $2,693.82 / $2,693.82
| Professional | | $2,693.82 | $2,693.82 | $2,693.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.28 / $2,059.28 / $2,059.28
| Professional | | $2,059.28 | $2,059.28 | $2,059.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.07 / $1,500.71 / $1,978.43
| Professional | | $1,190.07 | $1,500.71 | $1,978.43 |