- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.94 / $703.27 / $1,173.59
| Professional | | $631.94 | $703.27 | $1,173.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.50 / $1,314.50 / $1,314.50
| Professional | | $1,314.50 | $1,314.50 | $1,314.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $816.59 / $816.59 / $968.40
| Facility | | $816.59 | $816.59 | $968.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.43 / $816.59 / $1,151.25
| Professional | | $92.43 | $816.59 | $1,151.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.36 / $506.05 / $1,102.19
| Professional | | $337.36 | $506.05 | $1,102.19 |