- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,123.32 / $10,833.10 / $10,833.10
| Professional | | $3,123.32 | $10,833.10 | $10,833.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.18 / $3,637.95 / $3,637.95
| Facility | | $1,769.18 | $3,637.95 | $3,637.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,769.18 / $2,958.42 / $3,637.95
| Professional | | $1,769.18 | $2,958.42 | $3,637.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,578.52 / $3,464.71 / $3,637.95
| Facility | | $1,578.52 | $3,464.71 | $3,637.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,769.18 / $2,730.45 / $3,640.60
| Professional | | $1,769.18 | $2,730.45 | $3,640.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.98 / $1,412.51 / $2,240.23
| Professional | | $1,305.98 | $1,412.51 | $2,240.23 |