- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.62 / $206.62 / $206.62
| Professional | | $206.62 | $206.62 | $206.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,064.11 / $1,064.11 / $1,064.11
| Facility | | $1,064.11 | $1,064.11 | $1,064.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.29 / $281.83 / $803.98
| Professional | | $244.29 | $281.83 | $803.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.29 / $281.83 / $803.98
| Professional | | $244.29 | $281.83 | $803.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.75 / $265.73 / $439.09
| Professional | | $177.75 | $265.73 | $439.09 |