- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Professional | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $275.42 / $436.52
| Facility | | $123.03 | $275.42 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $234.42 / $524.81
| Professional | | $169.82 | $234.42 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,019.95 / $19,498.45
| Facility | | $1,995.26 | $3,019.95 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Professional | | $3,019.95 | $3,019.95 | $3,019.95 |