- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,106.80 / $7,307.33 / $7,307.33
| Professional | | $2,106.80 | $7,307.33 | $7,307.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,665.63 / $2,765.91 / $2,765.91
| Facility | | $1,665.63 | $2,765.91 | $2,765.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.63 / $2,249.27 / $2,765.91
| Professional | | $1,665.63 | $2,249.27 | $2,765.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.83 / $2,634.20 / $2,765.91
| Facility | | $1,275.83 | $2,634.20 | $2,765.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,665.63 / $2,075.94 / $2,767.92
| Professional | | $1,665.63 | $2,075.94 | $2,767.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.83 / $1,141.66 / $1,810.65
| Professional | | $1,031.83 | $1,141.66 | $1,810.65 |