- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.01 / $1,945.85 / $1,945.85
| Professional | | $348.01 | $1,945.85 | $1,945.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $438.80 / $514.45 / $1,724.93
| Facility | | $438.80 | $514.45 | $1,724.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.75 / $438.80 / $438.80
| Professional | | $28.75 | $438.80 | $438.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $438.80 / $514.45 / $1,724.93
| Facility | | $438.80 | $514.45 | $1,724.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.36 / $272.36 / $438.80
| Professional | | $272.36 | $272.36 | $438.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.62 / $302.62 / $302.62
| Facility | | $302.62 | $302.62 | $302.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.89 / $127.10 / $181.57
| Professional | | $23.89 | $127.10 | $181.57 |