- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.80 / $1,348.96 / $1,364.12
| Professional | | $791.80 | $1,348.96 | $1,364.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.19 / $1,367.19 / $1,367.19
| Professional | | $1,367.19 | $1,367.19 | $1,367.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.58 / $1,116.58 / $1,116.58
| Facility | | $1,116.58 | $1,116.58 | $1,116.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.58 / $1,116.58 / $1,974.00
| Professional | | $1,116.58 | $1,116.58 | $1,974.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.79 / $859.28 / $1,329.32
| Professional | | $553.79 | $859.28 | $1,329.32 |