- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,591.15 / $2,106.00 / $3,002.96
| Professional | | $1,591.15 | $2,106.00 | $3,002.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,671.66 / $2,671.66 / $2,671.66
| Facility | | $2,671.66 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,270.91 / $2,671.66 / $2,671.66
| Professional | | $2,270.91 | $2,671.66 | $2,671.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,602.60 / $2,602.60 / $3,895.63
| Professional | | $2,602.60 | $2,602.60 | $3,895.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,613.67 / $2,347.16 / $2,933.96
| Professional | | $1,613.67 | $2,347.16 | $2,933.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.08 / $1,575.56 / $2,366.07
| Professional | | $1,268.08 | $1,575.56 | $2,366.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,852.72 / $2,852.72 / $2,852.72
| Professional | | $2,852.72 | $2,852.72 | $2,852.72 |