- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,949.84 / $2,511.89
| Facility | | $1,698.24 | $1,949.84 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,698.24 / $2,344.23
| Professional | | $1,445.44 | $1,698.24 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,630.27 / $3,388.44
| Professional | | $1,202.26 | $2,630.27 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $3,162.28
| Professional | | $1,412.54 | $1,862.09 | $3,162.28 |