- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.09 / $1,426.70 / $1,641.69
| Professional | | $1,240.09 | $1,426.70 | $1,641.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.60 / $1,143.60 / $1,317.41
| Professional | | $1,143.60 | $1,143.60 | $1,317.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.70 / $396.70 / $396.70
| Facility | | $396.70 | $396.70 | $396.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.20 / $396.70 / $396.70
| Professional | | $337.20 | $396.70 | $396.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.90 / $962.44 / $1,283.18
| Professional | | $590.90 | $962.44 | $1,283.18 |