- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.63 / $1,057.01 / $1,057.01
| Professional | | $232.63 | $1,057.01 | $1,057.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.63 / $318.63 / $318.63
| Professional | | $318.63 | $318.63 | $318.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.63 / $318.63 / $318.63
| Facility | | $318.63 | $318.63 | $318.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.49 / $318.63 / $318.63
| Professional | | $268.49 | $318.63 | $318.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.63 / $318.63 / $318.63
| Facility | | $318.63 | $318.63 | $318.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.66 / $280.02 / $427.70
| Professional | | $197.66 | $280.02 | $427.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.08 / $362.40 / $559.63
| Professional | | $311.08 | $362.40 | $559.63 |