- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,838.74 / $2,421.66 / $9,159.02
| Professional | | $1,838.74 | $2,421.66 | $9,159.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,726.80 / $2,726.80 / $2,726.80
| Facility | | $2,726.80 | $2,726.80 | $2,726.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,400.78 / $2,726.80 / $2,913.49
| Professional | | $1,400.78 | $2,726.80 | $2,913.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,351.41 / $1,858.19 / $2,726.80
| Facility | | $1,351.41 | $1,858.19 | $2,726.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.88 / $2,726.80 / $3,591.70
| Professional | | $1,659.88 | $2,726.80 | $3,591.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,373.96 / $2,879.07 / $3,232.64
| Professional | | $2,373.96 | $2,879.07 | $3,232.64 |