- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.23 / $1,048.23 / $1,190.32
| Professional | | $1,048.23 | $1,048.23 | $1,190.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.85 / $309.85 / $309.85
| Facility | | $309.85 | $309.85 | $309.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.98 / $415.98 / $415.98
| Professional | | $415.98 | $415.98 | $415.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.85 / $309.85 / $309.85
| Facility | | $309.85 | $309.85 | $309.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.33 / $120.33 / $415.98
| Professional | | $120.33 | $120.33 | $415.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.86 / $185.12 / $833.04
| Professional | | $80.86 | $185.12 | $833.04 |