- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.00 / $425.00 / $425.00
| Professional | | $375.00 | $425.00 | $425.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,901.48 / $2,901.48 / $2,901.48
| Facility | | $2,901.48 | $2,901.48 | $2,901.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $565.36 / $625.60 / $1,578.62
| Professional | | $565.36 | $625.60 | $1,578.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $565.36 / $625.60 / $1,027.06
| Professional | | $565.36 | $625.60 | $1,027.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $451.48 / $858.81 / $1,697.06
| Professional | | $451.48 | $858.81 | $1,697.06 |