- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,859.29 / $1,859.29 / $2,145.34
| Professional | | $1,859.29 | $1,859.29 | $2,145.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.81 / $1,815.81 / $2,800.38
| Facility | | $1,815.81 | $1,815.81 | $2,800.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.54 / $1,815.81 / $1,935.74
| Professional | | $1,325.54 | $1,815.81 | $1,935.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.81 / $1,815.81 / $2,800.38
| Facility | | $1,815.81 | $1,815.81 | $2,800.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.54 / $1,815.81 / $1,935.74
| Professional | | $1,325.54 | $1,815.81 | $1,935.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.21 / $2,256.98 / $4,404.66
| Professional | | $1,267.21 | $2,256.98 | $4,404.66 |