- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.41 / $1,042.41 / $1,042.41
| Professional | | $1,042.41 | $1,042.41 | $1,042.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,407.03 / $1,407.03 / $1,407.03
| Facility | | $1,407.03 | $1,407.03 | $1,407.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.01 / $966.01 / $1,207.51
| Professional | | $966.01 | $966.01 | $1,207.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,407.03 / $1,407.03 / $1,407.03
| Facility | | $1,407.03 | $1,407.03 | $1,407.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.41 / $966.01 / $1,207.51
| Professional | | $546.41 | $966.01 | $1,207.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.39 / $504.39 / $1,176.91
| Professional | | $504.39 | $504.39 | $1,176.91 |