- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.60 / $543.60 / $992.80
| Professional | | $543.60 | $543.60 | $992.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.30 / $1,107.30 / $1,107.30
| Professional | | $1,107.30 | $1,107.30 | $1,107.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $428.20 / $428.20 / $933.64
| Facility | | $428.20 | $428.20 | $933.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.20 / $428.20 / $428.20
| Professional | | $428.20 | $428.20 | $428.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.89 / $413.50 / $589.69
| Professional | | $349.89 | $413.50 | $589.69 |