- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.82 / $1,516.82 / $1,579.04
| Professional | | $1,516.82 | $1,516.82 | $1,579.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.48 / $1,261.72 / $1,865.61
| Professional | | $980.48 | $1,261.72 | $1,865.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $712.05 / $712.05 / $712.05
| Facility | | $712.05 | $712.05 | $712.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.25 / $1,774.06 / $2,123.40
| Professional | | $1,211.25 | $1,774.06 | $2,123.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,204.45 / $1,393.55 / $2,137.78
| Professional | | $1,204.45 | $1,393.55 | $2,137.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,516.82 / $1,516.82 / $1,516.82
| Professional | | $1,516.82 | $1,516.82 | $1,516.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.48 / $1,372.40 / $1,774.65
| Professional | | $946.48 | $1,372.40 | $1,774.65 |