- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,862.09 / $3,162.28
| Professional | | $1,621.81 | $1,862.09 | $3,162.28 |
- 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
- $2,398.83 / $2,398.83 / $3,630.78
| Facility | | $2,398.83 | $2,398.83 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $3,162.28
| Professional | | $1,778.28 | $1,778.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,089.30 / $2,691.53
| Facility | | $1,202.26 | $2,089.30 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,584.89 / $2,454.71
| Professional | | $1,412.54 | $1,584.89 | $2,454.71 |