- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.50 / $241.93 / $930.86
| Professional | | $179.50 | $241.93 | $930.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,686.50 / $2,686.50 / $3,233.54
| Facility | | $2,686.50 | $2,686.50 | $3,233.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.20 / $682.75 / $1,406.80
| Professional | | $579.20 | $682.75 | $1,406.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.31 / $399.33 / $1,406.80
| Professional | | $251.31 | $399.33 | $1,406.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.23 / $573.13 / $1,406.80
| Professional | | $256.23 | $573.13 | $1,406.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.70 / $520.28 / $1,726.70
| Professional | | $262.70 | $520.28 | $1,726.70 |