- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.92 / $10,616.60 / $10,616.60
| Professional | | $3,060.92 | $10,616.60 | $10,616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.88 / $4,001.95 / $4,001.95
| Facility | | $2,677.88 | $4,001.95 | $4,001.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,677.88 / $3,254.42 / $4,001.95
| Professional | | $2,677.88 | $3,254.42 | $4,001.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,889.43 / $3,811.38 / $4,001.95
| Facility | | $1,889.43 | $3,811.38 | $4,001.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,677.88 / $3,003.64 / $4,004.86
| Professional | | $2,677.88 | $3,003.64 | $4,004.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.10 / $1,690.72 / $2,681.48
| Professional | | $1,528.10 | $1,690.72 | $2,681.48 |