- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.20 / $2,601.06 / $2,601.06
| Professional | | $465.20 | $2,601.06 | $2,601.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $586.54 / $687.68 / $2,305.76
| Facility | | $586.54 | $687.68 | $2,305.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.54 / $586.54 / $586.54
| Professional | | $586.54 | $586.54 | $586.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $586.54 / $687.68 / $2,305.76
| Facility | | $586.54 | $687.68 | $2,305.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.07 / $364.07 / $586.54
| Professional | | $364.07 | $364.07 | $586.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.71 / $169.90 / $404.52
| Professional | | $137.71 | $169.90 | $404.52 |