- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,071.52 / $1,445.44
| Professional | | $645.65 | $1,071.52 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,148.15
| Professional | | $1,000.00 | $1,000.00 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $436.52 / $512.86
| Professional | | $134.90 | $436.52 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Professional | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $776.25 / $1,148.15
| Facility | | $102.33 | $776.25 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $741.31 / $933.25
| Professional | | $512.86 | $741.31 | $933.25 |