- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.81 / $2,112.86 / $2,112.86
| Professional | | $463.81 | $2,112.86 | $2,112.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $640.41 / $640.41 / $640.41
| Facility | | $640.41 | $640.41 | $640.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.97 / $640.41 / $640.41
| Professional | | $487.97 | $640.41 | $640.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $640.41 / $727.35 / $752.68
| Facility | | $640.41 | $727.35 | $752.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.02 / $558.21 / $852.60
| Professional | | $394.02 | $558.21 | $852.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.69 / $724.80 / $1,124.80
| Professional | | $570.69 | $724.80 | $1,124.80 |