- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.80 / $261.80 / $261.80
| Professional | | $261.80 | $261.80 | $261.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,087.00 / $3,377.18 / $4,730.21
| Professional | | $3,087.00 | $3,377.18 | $4,730.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $360.79 / $360.79 / $360.79
| Facility | | $360.79 | $360.79 | $360.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $261.80 / $274.89 / $3,300.77
| Facility | | $261.80 | $274.89 | $3,300.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |