- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,801.27 / $1,801.27 / $1,801.27
| Professional | | $1,801.27 | $1,801.27 | $1,801.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.26 / $143.26 / $276.62
| Professional | | $143.26 | $143.26 | $276.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.98 / $249.98 / $261.76
| Professional | | $249.98 | $249.98 | $261.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.39 / $245.88 / $256.13
| Professional | | $225.39 | $245.88 | $256.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.62 / $2,170.19 / $3,255.30
| Professional | | $276.62 | $2,170.19 | $3,255.30 |