- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $843.53 / $843.53 / $1,400.00
| Facility | | $843.53 | $843.53 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.73 / $1,192.27 / $1,345.84
| Professional | | $912.73 | $1,192.27 | $1,345.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,404.20 / $1,404.20 / $1,404.20
| Facility | | $1,404.20 | $1,404.20 | $1,404.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.10 / $1,109.10 / $1,109.10
| Professional | | $1,109.10 | $1,109.10 | $1,109.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.70 / $1,301.44 / $1,946.03
| Professional | | $898.70 | $1,301.44 | $1,946.03 |