- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.10 / $1,317.10 / $2,306.60
| Professional | | $1,317.10 | $1,317.10 | $2,306.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,572.46 / $2,572.46 / $2,572.46
| Facility | | $2,572.46 | $2,572.46 | $2,572.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,572.46 / $2,572.46 / $2,572.46
| Professional | | $2,572.46 | $2,572.46 | $2,572.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,665.63 / $1,665.63 / $2,517.23
| Facility | | $1,665.63 | $1,665.63 | $2,517.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.91 / $1,215.91 / $1,665.63
| Professional | | $1,215.91 | $1,215.91 | $1,665.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.83 / $1,522.21 / $1,759.25
| Professional | | $1,031.83 | $1,522.21 | $1,759.25 |