- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.28 / $575.28 / $965.07
| Professional | | $575.28 | $575.28 | $965.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,722.03 / $2,722.03 / $3,486.12
| Facility | | $2,722.03 | $2,722.03 | $3,486.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.29 / $358.29 / $358.29
| Professional | | $358.29 | $358.29 | $358.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.29 / $358.29 / $358.29
| Professional | | $358.29 | $358.29 | $358.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.60 / $676.80 / $1,563.68
| Professional | | $507.60 | $676.80 | $1,563.68 |