- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,913.85 / $1,913.85 / $2,208.29
| Professional | | $1,913.85 | $1,913.85 | $2,208.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.78 / $1,902.78 / $2,882.56
| Facility | | $1,902.78 | $1,902.78 | $2,882.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.03 / $1,902.78 / $1,959.86
| Professional | | $1,389.03 | $1,902.78 | $1,959.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.78 / $1,902.78 / $2,882.56
| Facility | | $1,902.78 | $1,902.78 | $2,882.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.03 / $1,902.78 / $1,959.86
| Professional | | $1,389.03 | $1,902.78 | $1,959.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,467.45 / $3,159.24 / $3,260.99
| Professional | | $1,467.45 | $3,159.24 | $3,260.99 |