- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,336.09 / $2,086.73
| Professional | | $1,214.63 | $1,336.09 | $2,086.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,589.05 / $2,956.38 / $3,662.92
| Facility | | $2,589.05 | $2,956.38 | $3,662.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Professional | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Professional | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.90 / $1,214.63 / $1,287.51
| Professional | | $1,153.90 | $1,214.63 | $1,287.51 |