- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,700.11 / $1,700.11 / $2,658.35
| Professional | | $1,700.11 | $1,700.11 | $2,658.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,964.76 / $2,964.76 / $2,964.76
| Facility | | $2,964.76 | $2,964.76 | $2,964.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,964.76 / $2,964.76 / $2,964.76
| Professional | | $2,964.76 | $2,964.76 | $2,964.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,815.81 / $1,815.81 / $3,410.50
| Facility | | $1,815.81 | $1,815.81 | $3,410.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.54 / $1,325.54 / $1,815.81
| Professional | | $1,325.54 | $1,325.54 | $1,815.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.30 / $1,449.74 / $1,609.50
| Professional | | $1,310.30 | $1,449.74 | $1,609.50 |