- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $666.20 / $666.20 / $1,481.20
| Professional | | $666.20 | $666.20 | $1,481.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,293.59 / $1,293.59 / $1,293.59
| Professional | | $1,293.59 | $1,293.59 | $1,293.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $936.57 / $936.57 / $936.57
| Facility | | $936.57 | $936.57 | $936.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.08 / $796.08 / $936.57
| Professional | | $796.08 | $796.08 | $936.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.19 / $122.68 / $2,290.63
| Professional | | $78.19 | $122.68 | $2,290.63 |