- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $3,019.95
| Professional | | $1,949.84 | $1,949.84 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $1,445.44 / $2,290.87
| Professional | | $234.42 | $1,445.44 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,548.13 / $4,570.88
| Professional | | $3,388.44 | $3,548.13 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $234.42 / $2,238.72
| Professional | | $234.42 | $234.42 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $1,230.27 / $2,187.76
| Facility | | $162.18 | $1,230.27 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,238.72 / $3,162.28
| Professional | | $1,230.27 | $2,238.72 | $3,162.28 |