- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.63 / $1,771.38 / $1,771.38
| Professional | | $1,322.63 | $1,771.38 | $1,771.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,850.09 / $1,850.09 / $1,850.09
| Facility | | $1,850.09 | $1,850.09 | $1,850.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,572.58 / $1,572.58 / $1,572.58
| Professional | | $1,572.58 | $1,572.58 | $1,572.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,850.09 / $1,850.09 / $1,850.09
| Facility | | $1,850.09 | $1,850.09 | $1,850.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.76 / $2,599.80 / $2,976.32
| Professional | | $1,036.76 | $2,599.80 | $2,976.32 |