- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $748.07 / $1,797.34 / $2,066.92
| Facility | | $748.07 | $1,797.34 | $2,066.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.07 / $748.07 / $1,255.41
| Professional | | $748.07 | $748.07 | $1,255.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.83 / $794.83 / $794.83
| Professional | | $794.83 | $794.83 | $794.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,421.33 / $3,853.40 / $3,853.40
| Facility | | $1,421.33 | $3,853.40 | $3,853.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,226.53 / $1,387.22 / $1,561.04
| Facility | | $1,226.53 | $1,387.22 | $1,561.04 |