- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,137.96 / $4,677.35
| Professional | | $1,548.82 | $2,137.96 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,630.27 / $2,818.38
| Professional | | $1,698.24 | $2,630.27 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,884.03 / $3,235.94
| Facility | | $2,754.23 | $2,884.03 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,884.03 / $3,235.94
| Professional | | $2,754.23 | $2,884.03 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,398.83 / $2,884.03
| Facility | | $1,513.56 | $2,398.83 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,698.24 / $3,467.37
| Professional | | $79.43 | $1,698.24 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,754.23 / $4,073.80
| Professional | | $2,238.72 | $2,754.23 | $4,073.80 |