- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.32 / $1,188.32 / $1,188.32
| Professional | | $1,188.32 | $1,188.32 | $1,188.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,729.36 / $1,729.36 / $1,729.36
| Facility | | $1,729.36 | $1,729.36 | $1,729.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.36 / $1,729.36 / $1,729.36
| Professional | | $1,729.36 | $1,729.36 | $1,729.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.74 / $1,024.73 / $1,729.36
| Facility | | $195.74 | $1,024.73 | $1,729.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.36 / $1,849.93 / $2,802.80
| Professional | | $1,729.36 | $1,849.93 | $2,802.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,801.80 / $2,196.10 / $2,841.29
| Professional | | $1,801.80 | $2,196.10 | $2,841.29 |