- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.43 / $821.43 / $1,438.54
| Professional | | $821.43 | $821.43 | $1,438.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,604.35 / $1,604.35 / $1,604.35
| Facility | | $1,604.35 | $1,604.35 | $1,604.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.35 / $1,604.35 / $1,604.35
| Professional | | $1,604.35 | $1,604.35 | $1,604.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,232.20 / $1,232.20 / $1,898.60
| Facility | | $1,232.20 | $1,232.20 | $1,898.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.51 / $899.51 / $1,232.20
| Professional | | $899.51 | $899.51 | $1,232.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.48 / $861.08 / $1,141.43
| Professional | | $669.48 | $861.08 | $1,141.43 |