- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,441.63 / $2,441.63 / $4,275.93
| Professional | | $2,441.63 | $2,441.63 | $4,275.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,768.80 / $4,768.80 / $4,768.80
| Facility | | $4,768.80 | $4,768.80 | $4,768.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,768.80 / $4,768.80 / $4,768.80
| Professional | | $4,768.80 | $4,768.80 | $4,768.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,886.72 / $2,886.72 / $5,287.19
| Facility | | $2,886.72 | $2,886.72 | $5,287.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.31 / $2,107.31 / $2,886.72
| Professional | | $2,107.31 | $2,107.31 | $2,886.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,945.66 / $2,870.29 / $3,317.27
| Professional | | $1,945.66 | $2,870.29 | $3,317.27 |