- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,988.07 / $2,988.07 / $2,988.07
| Professional | | $2,988.07 | $2,988.07 | $2,988.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,787.17 / $1,787.17 / $1,787.17
| Facility | | $1,787.17 | $1,787.17 | $1,787.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.63 / $1,304.63 / $1,304.63
| Professional | | $1,304.63 | $1,304.63 | $1,304.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $789.12 / $789.12 / $789.12
| Facility | | $789.12 | $789.12 | $789.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,719.64 / $3,241.71 / $5,118.50
| Professional | | $2,719.64 | $3,241.71 | $5,118.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $789.12 / $789.12 / $1,787.17
| Facility | | $789.12 | $789.12 | $1,787.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.63 / $2,123.19 / $3,354.82
| Professional | | $1,304.63 | $2,123.19 | $3,354.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,702.37 / $1,702.37 / $3,262.88
| Professional | | $1,702.37 | $1,702.37 | $3,262.88 |