- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,065.18 / $1,065.18 / $1,278.22
| Facility | | $1,065.18 | $1,065.18 | $1,278.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.70 / $1,065.18 / $1,114.07
| Professional | | $772.70 | $1,065.18 | $1,114.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.67 / $806.67 / $1,464.54
| Professional | | $806.67 | $806.67 | $1,464.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $845.38 / $845.38 / $845.38
| Facility | | $845.38 | $845.38 | $845.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $718.57 / $718.57 / $845.38
| Professional | | $718.57 | $718.57 | $845.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.17 / $89.72 / $400.09
| Professional | | $45.17 | $89.72 | $400.09 |