- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.72 / $1,905.72 / $3,337.43
| Professional | | $1,905.72 | $1,905.72 | $3,337.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,722.11 / $3,722.11 / $3,722.11
| Facility | | $3,722.11 | $3,722.11 | $3,722.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,722.11 / $3,722.11 / $3,722.11
| Professional | | $3,722.11 | $3,722.11 | $3,722.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,117.90 / $2,117.90 / $4,140.47
| Facility | | $2,117.90 | $2,117.90 | $4,140.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.07 / $1,546.07 / $3,365.03
| Professional | | $1,546.07 | $1,546.07 | $3,365.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.30 / $1,690.94 / $2,605.67
| Professional | | $1,528.30 | $1,690.94 | $2,605.67 |