- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.66 / $846.27 / $3,136.30
| Professional | | $639.66 | $846.27 | $3,136.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $962.74 / $962.74 / $962.74
| Facility | | $962.74 | $962.74 | $962.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $495.09 / $962.74 / $998.71
| Professional | | $495.09 | $962.74 | $998.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $476.78 / $655.58 / $962.74
| Facility | | $476.78 | $655.58 | $962.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.41 / $962.74 / $1,251.59
| Professional | | $578.41 | $962.74 | $1,251.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.80 / $972.07 / $1,102.71
| Professional | | $809.80 | $972.07 | $1,102.71 |