- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.69 / $801.69 / $1,002.12
| Professional | | $801.69 | $801.69 | $1,002.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,930.50 / $3,930.50 / $3,930.50
| Facility | | $3,930.50 | $3,930.50 | $3,930.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.00 / $3,597.38 / $3,597.38
| Professional | | $681.00 | $3,597.38 | $3,597.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.00 / $681.00 / $681.00
| Facility | | $681.00 | $681.00 | $681.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.00 / $760.05 / $887.00
| Professional | | $624.00 | $760.05 | $887.00 |