- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,481.49 / $4,481.49 / $4,481.49
| Professional | | $4,481.49 | $4,481.49 | $4,481.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,479.82 / $2,479.82 / $2,479.82
| Facility | | $2,479.82 | $2,479.82 | $2,479.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.27 / $2,479.82 / $2,554.21
| Professional | | $1,810.27 | $2,479.82 | $2,554.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.71 / $1,000.71 / $1,000.71
| Facility | | $1,000.71 | $1,000.71 | $1,000.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,935.64 / $4,861.89 / $7,676.69
| Professional | | $3,935.64 | $4,861.89 | $7,676.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.71 / $1,000.71 / $2,479.82
| Facility | | $1,000.71 | $1,000.71 | $2,479.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,810.27 / $2,554.21 / $3,943.16
| Professional | | $1,810.27 | $2,554.21 | $3,943.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,473.54 / $2,553.21 / $4,893.64
| Professional | | $2,473.54 | $2,553.21 | $4,893.64 |