- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.96 / $724.45 / $3,756.60
| Professional | | $408.96 | $724.45 | $3,756.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.86 / $977.86 / $977.86
| Facility | | $977.86 | $977.86 | $977.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.95 / $660.91 / $1,312.80
| Professional | | $277.95 | $660.91 | $1,312.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.86 / $977.86 / $977.86
| Facility | | $977.86 | $977.86 | $977.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.95 / $660.91 / $1,312.80
| Professional | | $277.95 | $660.91 | $1,312.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.19 / $584.23 / $2,629.04
| Professional | | $255.19 | $584.23 | $2,629.04 |