- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.75 / $1,408.75 / $2,443.69
| Professional | | $1,408.75 | $1,408.75 | $2,443.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,725.40 / $2,725.40 / $2,725.40
| Professional | | $2,725.40 | $2,725.40 | $2,725.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,414.26 / $1,414.26 / $2,320.44
| Facility | | $1,414.26 | $1,414.26 | $2,320.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,414.26 / $1,414.26 / $1,414.26
| Professional | | $1,414.26 | $1,414.26 | $1,414.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.83 / $1,377.36 / $1,691.76
| Professional | | $1,194.83 | $1,377.36 | $1,691.76 |