- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,343.08 / $1,343.08 / $2,767.17
| Professional | | $1,343.08 | $1,343.08 | $2,767.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,086.12 / $3,086.12 / $3,086.12
| Professional | | $3,086.12 | $3,086.12 | $3,086.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $3,476.21
| Facility | | $1,786.79 | $1,786.79 | $3,476.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $1,786.79
| Professional | | $1,786.79 | $1,786.79 | $1,786.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.77 / $1,340.09 / $2,018.65
| Professional | | $1,135.77 | $1,340.09 | $2,018.65 |