- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.20 / $483.20 / $510.81
| Professional | | $483.20 | $483.20 | $510.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $1,415.48 / $1,598.02
| Facility | | $0.02 | $1,415.48 | $1,598.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.63 / $914.63 / $914.63
| Professional | | $914.63 | $914.63 | $914.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,040.68 / $2,040.68 / $2,040.68
| Facility | | $2,040.68 | $2,040.68 | $2,040.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.92 / $414.17 / $995.61
| Professional | | $289.92 | $414.17 | $995.61 |