- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,315.44 / $8,030.97 / $8,030.97
| Professional | | $2,315.44 | $8,030.97 | $8,030.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,620.00 / $2,481.94 / $2,481.94
| Facility | | $1,620.00 | $2,481.94 | $2,481.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.00 / $2,018.35 / $2,481.94
| Professional | | $1,620.00 | $2,018.35 | $2,481.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,163.89 / $2,363.76 / $2,481.94
| Facility | | $1,163.89 | $2,363.76 | $2,481.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.00 / $1,862.81 / $2,483.75
| Professional | | $1,620.00 | $1,862.81 | $2,483.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.31 / $1,041.48 / $1,735.80
| Professional | | $941.31 | $1,041.48 | $1,735.80 |