- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.86 / $998.86 / $1,561.84
| Professional | | $998.86 | $998.86 | $1,561.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,741.87 / $1,741.87 / $1,741.87
| Facility | | $1,741.87 | $1,741.87 | $1,741.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.87 / $1,741.87 / $1,741.87
| Professional | | $1,741.87 | $1,741.87 | $1,741.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.53 / $1,395.53 / $2,007.65
| Facility | | $1,395.53 | $1,395.53 | $2,007.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.74 / $1,018.74 / $1,770.90
| Professional | | $1,018.74 | $1,018.74 | $1,770.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.26 / $889.85 / $987.91
| Professional | | $804.26 | $889.85 | $987.91 |