- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $921.23 / $921.23 / $921.23
| Facility | | $921.23 | $921.23 | $921.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.00 / $531.44 / $798.38
| Professional | | $85.00 | $531.44 | $798.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $872.53 / $1,059.13 / $1,433.38
| Facility | | $872.53 | $1,059.13 | $1,433.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.51 / $291.51 / $291.51
| Professional | | $291.51 | $291.51 | $291.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.40 / $440.40 / $440.40
| Professional | | $440.40 | $440.40 | $440.40 |