- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $3,630.78
| Professional | | $1,698.24 | $2,041.74 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $4,073.80
| Facility | | $2,754.23 | $2,754.23 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $3,388.44
| Professional | | $2,041.74 | $2,041.74 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,238.72 / $2,691.53
| Facility | | $1,288.25 | $2,238.72 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,698.24 / $2,630.27
| Professional | | $1,513.56 | $1,698.24 | $2,630.27 |