- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.84 / $1,538.84 / $1,775.59
| Professional | | $1,538.84 | $1,538.84 | $1,775.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,317.73 / $2,373.71 / $2,373.71
| Facility | | $2,317.73 | $2,373.71 | $2,373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,663.35 / $2,017.65 / $2,444.92
| Professional | | $1,663.35 | $2,017.65 | $2,444.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,317.73 / $2,373.71 / $2,373.71
| Facility | | $2,317.73 | $2,373.71 | $2,373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,663.35 / $2,373.71 / $2,444.92
| Professional | | $1,663.35 | $2,373.71 | $2,444.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.81 / $2,007.74 / $3,645.52
| Professional | | $1,048.81 | $2,007.74 | $3,645.52 |