- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,655.06 / $2,655.06 / $2,655.06
| Professional | | $2,655.06 | $2,655.06 | $2,655.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,427.45
| Facility | | $1,427.45 | $1,427.45 | $1,427.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $2,019.98
| Professional | | $1,427.45 | $1,427.45 | $2,019.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.73 / $2,655.06 / $3,717.08
| Facility | | $1,370.73 | $2,655.06 | $3,717.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,427.45 / $1,855.69
| Professional | | $1,427.45 | $1,427.45 | $1,855.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,436.00 / $2,784.00 / $3,828.00
| Facility | | $2,436.00 | $2,784.00 | $3,828.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,542.17 / $1,914.00 / $2,088.00
| Professional | | $1,542.17 | $1,914.00 | $2,088.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,427.45 / $2,655.06 / $3,717.08
| Facility | | $1,427.45 | $2,655.06 | $3,717.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.45 / $1,844.40 / $2,088.00
| Professional | | $1,427.45 | $1,844.40 | $2,088.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,141.17 / $2,141.17 / $4,282.35
| Professional | | $2,141.17 | $2,141.17 | $4,282.35 |