- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.50 / $1,077.50 / $1,346.87
| Professional | | $1,077.50 | $1,077.50 | $1,346.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,968.66 / $1,968.66 / $1,968.66
| Facility | | $1,968.66 | $1,968.66 | $1,968.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.00 / $3,807.00 / $3,807.00
| Professional | | $912.00 | $3,807.00 | $3,807.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $597.33 / $774.13 / $990.90
| Facility | | $597.33 | $774.13 | $990.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.33 / $990.90 / $1,074.82
| Professional | | $597.33 | $990.90 | $1,074.82 |