- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.60 / $729.60 / $729.60
| Professional | | $729.60 | $729.60 | $729.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $368.13 / $563.38 / $987.84
| Facility | | $368.13 | $563.38 | $987.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,117.16 / $2,117.16 / $2,117.16
| Professional | | $2,117.16 | $2,117.16 | $2,117.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $366.00 / $1,438.00 / $2,720.00
| Facility | | $366.00 | $1,438.00 | $2,720.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $382.00 / $1,727.00 / $2,883.00
| Facility | | $382.00 | $1,727.00 | $2,883.00 |