- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,617.73 / $1,617.73 / $1,866.61
| Professional | | $1,617.73 | $1,617.73 | $1,866.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,436.54 / $2,637.76 / $2,637.76
| Facility | | $2,436.54 | $2,637.76 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $2,623.38 / $2,716.89
| Professional | | $1,925.56 | $2,623.38 | $2,716.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,436.54 / $2,637.76 / $2,637.76
| Facility | | $2,436.54 | $2,637.76 | $2,637.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $2,637.76 / $2,716.89
| Professional | | $1,925.56 | $2,637.76 | $2,716.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.67 / $2,491.30 / $3,832.39
| Professional | | $1,146.67 | $2,491.30 | $3,832.39 |