- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,230.27 / $1,445.44
| Professional | | $1,148.15 | $1,230.27 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,905.46 / $2,089.30
| Professional | | $1,778.28 | $1,905.46 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $19,952.62
| Facility | | $2,290.87 | $2,290.87 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $19,952.62
| Professional | | $2,290.87 | $2,290.87 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,380.38 / $2,089.30
| Facility | | $1,230.27 | $1,380.38 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,905.46 / $2,089.30
| Professional | | $1,778.28 | $1,905.46 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,187.76 / $2,511.89
| Professional | | $1,778.28 | $2,187.76 | $2,511.89 |