- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.52 / $501.52 / $501.52
| Facility | | $501.52 | $501.52 | $501.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.78 / $473.78 / $501.52
| Professional | | $473.78 | $473.78 | $501.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.53 / $762.06 / $781.02
| Professional | | $644.53 | $762.06 | $781.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.50 / $798.41 / $1,003.94
| Professional | | $790.50 | $798.41 | $1,003.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.08 / $501.52 / $3,175.29
| Facility | | $202.08 | $501.52 | $3,175.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.63 / $337.38 / $549.25
| Professional | | $274.63 | $337.38 | $549.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.95 / $354.54 / $681.87
| Professional | | $237.95 | $354.54 | $681.87 |