- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.40 / $1,661.55 / $1,661.55
| Professional | | $1,639.40 | $1,661.55 | $1,661.55 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $1,639.40 / $2,089.07 / $3,212.33
| Facility | | $1,639.40 | $2,089.07 | $3,212.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.47 / $930.47 / $11,032.69
| Professional | | $930.47 | $930.47 | $11,032.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.47 / $930.47 / $2,215.40
| Professional | | $930.47 | $930.47 | $2,215.40 |