- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,921.65 / $2,073.86 / $2,207.04
| Professional | | $1,921.65 | $2,073.86 | $2,207.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,682.46 / $2,682.46 / $2,682.46
| Facility | | $2,682.46 | $2,682.46 | $2,682.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $2,682.46 / $2,682.46
| Professional | | $1,902.62 | $2,682.46 | $2,682.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,902.62 / $2,682.46 / $2,812.50
| Facility | | $1,902.62 | $2,682.46 | $2,812.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,064.17 / $2,064.17 / $2,957.64
| Professional | | $2,064.17 | $2,064.17 | $2,957.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.62 / $1,902.62 / $1,902.62
| Professional | | $1,902.62 | $1,902.62 | $1,902.62 |