- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.20 / $1,181.56 / $1,181.56
| Professional | | $211.20 | $1,181.56 | $1,181.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.33 / $362.70 / $1,023.44
| Facility | | $269.33 | $362.70 | $1,023.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.53 / $293.39 / $571.33
| Professional | | $163.53 | $293.39 | $571.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.33 / $362.70 / $1,023.44
| Facility | | $269.33 | $362.70 | $1,023.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.09 / $260.31 / $355.90
| Professional | | $182.09 | $260.31 | $355.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.59 / $176.51 / $361.90
| Professional | | $158.59 | $176.51 | $361.90 |