- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.40 / $1,245.40 / $2,181.04
| Professional | | $1,245.40 | $1,245.40 | $2,181.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,432.42 / $2,432.42 / $2,432.42
| Facility | | $2,432.42 | $2,432.42 | $2,432.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,432.42 / $2,432.42 / $2,432.42
| Professional | | $2,432.42 | $2,432.42 | $2,432.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.30 / $1,167.30 / $2,054.91
| Facility | | $1,167.30 | $1,167.30 | $2,054.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.13 / $852.13 / $1,167.30
| Professional | | $852.13 | $852.13 | $1,167.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.33 / $1,242.64 / $1,436.15
| Professional | | $842.33 | $1,242.64 | $1,436.15 |