- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,069.69 / $1,069.69 / $1,337.11
| Professional | | $1,069.69 | $1,069.69 | $1,337.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $822.97 / $1,012.79 / $1,946.58
| Facility | | $822.97 | $1,012.79 | $1,946.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.00 / $2,567.06 / $2,567.06
| Professional | | $1,008.00 | $2,567.06 | $2,567.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,008.00 / $1,008.00 / $1,008.00
| Facility | | $1,008.00 | $1,008.00 | $1,008.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.23 / $958.96 / $1,096.93
| Professional | | $810.23 | $958.96 | $1,096.93 |