- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.05 / $635.05 / $1,112.15
| Professional | | $635.05 | $635.05 | $1,112.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,240.33 / $1,240.33 / $1,240.33
| Facility | | $1,240.33 | $1,240.33 | $1,240.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,240.33 / $1,240.33 / $1,240.33
| Professional | | $1,240.33 | $1,240.33 | $1,240.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $702.38 / $702.38 / $1,518.69
| Facility | | $702.38 | $702.38 | $1,518.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.74 / $512.74 / $702.38
| Professional | | $512.74 | $512.74 | $702.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.84 / $560.78 / $864.14
| Professional | | $506.84 | $560.78 | $864.14 |