- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,858.91 / $2,489.61 / $2,489.61
| Professional | | $1,858.91 | $2,489.61 | $2,489.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $2,672.64
| Facility | | $2,672.64 | $2,672.64 | $2,672.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,271.73 / $2,672.64 / $2,752.82
| Professional | | $2,271.73 | $2,672.64 | $2,752.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $2,672.64
| Facility | | $2,672.64 | $2,672.64 | $2,672.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $2,752.82
| Professional | | $2,672.64 | $2,672.64 | $2,752.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.85 / $3,120.86 / $3,412.13
| Professional | | $1,364.85 | $3,120.86 | $3,412.13 |