- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.72 / $944.72 / $1,654.45
| Professional | | $944.72 | $944.72 | $1,654.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,845.15 / $1,845.15 / $1,845.15
| Facility | | $1,845.15 | $1,845.15 | $1,845.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,845.15 / $1,845.15 / $1,845.15
| Professional | | $1,845.15 | $1,845.15 | $1,845.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,530.70 / $1,530.70 / $2,539.56
| Facility | | $1,530.70 | $1,530.70 | $2,539.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.41 / $1,117.41 / $1,761.91
| Professional | | $1,117.41 | $1,117.41 | $1,761.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.21 / $885.38 / $1,364.34
| Professional | | $800.21 | $885.38 | $1,364.34 |