- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.01 / $1,728.01 / $1,728.01
| Professional | | $1,728.01 | $1,728.01 | $1,728.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.26 / $336.26 / $1,340.31
| Professional | | $336.26 | $336.26 | $1,340.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.48 / $2,698.48 / $3,233.08
| Professional | | $2,698.48 | $2,698.48 | $3,233.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,215.40 / $2,215.40 / $2,215.40
| Professional | | $2,215.40 | $2,215.40 | $2,215.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,323.10 / $3,323.10 / $3,323.10
| Facility | | $3,323.10 | $3,323.10 | $3,323.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.47 / $930.47 / $2,215.40
| Professional | | $930.47 | $930.47 | $2,215.40 |