- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.17 / $656.17 / $1,149.13
| Professional | | $656.17 | $656.17 | $1,149.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,281.58 / $1,281.58 / $1,281.58
| Facility | | $1,281.58 | $1,281.58 | $1,281.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.58 / $1,281.58 / $1,281.58
| Professional | | $1,281.58 | $1,281.58 | $1,281.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.63 / $724.63 / $1,420.96
| Facility | | $724.63 | $724.63 | $1,420.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.98 / $528.98 / $724.63
| Professional | | $528.98 | $528.98 | $724.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.89 / $578.54 / $891.52
| Professional | | $522.89 | $578.54 | $891.52 |