- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,513.56
| Professional | | $1,258.93 | $1,258.93 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,148.15 / $1,412.54
| Facility | | $851.14 | $1,148.15 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $5,888.44
| Professional | | $1,318.26 | $1,318.26 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $870.96
| Facility | | $741.31 | $741.31 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Professional | | $1,318.26 | $1,318.26 | $1,318.26 |