- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.60 / $223.60 / $223.60
| Professional | | $223.60 | $223.60 | $223.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $975.26 / $975.26 / $975.26
| Facility | | $975.26 | $975.26 | $975.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $975.26 / $1,720.67
| Professional | | $161.82 | $975.26 | $1,720.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.97 / $1,114.33 / $2,753.07
| Facility | | $228.97 | $1,114.33 | $2,753.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $975.26 / $1,720.67
| Professional | | $161.82 | $975.26 | $1,720.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.54 / $963.59 / $1,605.99
| Professional | | $877.54 | $963.59 | $1,605.99 |