- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.96 / $2,099.56 / $2,099.56
| Professional | | $1,683.96 | $2,099.56 | $2,099.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,010.53 / $14,279.49 / $16,101.93
| Facility | | $11,010.53 | $14,279.49 | $16,101.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.58 / $1,788.51 / $2,673.31
| Professional | | $1,459.58 | $1,788.51 | $2,673.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.38 / $2,099.56 / $2,926.80
| Professional | | $1,710.38 | $2,099.56 | $2,926.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.78 / $1,707.33 / $2,656.61
| Professional | | $1,533.78 | $1,707.33 | $2,656.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,683.96 / $2,099.56 / $2,099.56
| Professional | | $1,683.96 | $2,099.56 | $2,099.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.86 / $2,068.58 / $2,647.25
| Professional | | $1,415.86 | $2,068.58 | $2,647.25 |