- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.61 / $1,263.61 / $1,579.52
| Professional | | $1,263.61 | $1,263.61 | $1,579.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $781.10 / $1,092.44 / $1,546.17
| Facility | | $781.10 | $1,092.44 | $1,546.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.00 / $1,049.31 / $4,522.00
| Professional | | $818.00 | $1,049.31 | $4,522.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.00 / $1,005.00 / $1,005.00
| Facility | | $1,005.00 | $1,005.00 | $1,005.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.00 / $1,005.00 / $1,174.84
| Professional | | $818.00 | $1,005.00 | $1,174.84 |