- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,162.28
| Professional | | $2,570.40 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,148.15 / $5,495.41
| Facility | | $776.25 | $1,148.15 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,023.29 / $2,344.23
| Professional | | $549.54 | $1,023.29 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $1,905.46
| Facility | | $1,096.48 | $1,445.44 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $831.76 / $1,230.27
| Professional | | $549.54 | $831.76 | $1,230.27 |