- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $575.44 / $891.25
| Professional | | $501.19 | $575.44 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,023.29
| Professional | | $812.83 | $812.83 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $707.95
| Facility | | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $426.58 / $1,000.00
| Professional | | $309.03 | $426.58 | $1,000.00 |