- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.96 / $3,142.08 / $3,142.08
| Professional | | $561.96 | $3,142.08 | $3,142.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $708.56 / $830.72 / $2,785.36
| Facility | | $708.56 | $830.72 | $2,785.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.81 / $708.56 / $708.56
| Professional | | $335.81 | $708.56 | $708.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $708.56 / $830.72 / $2,785.36
| Facility | | $708.56 | $830.72 | $2,785.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $439.79 / $439.79 / $708.56
| Professional | | $439.79 | $439.79 | $708.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.24 / $205.24 / $488.66
| Professional | | $205.24 | $205.24 | $488.66 |