- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.39 / $1,091.56 / $1,091.56
| Professional | | $196.39 | $1,091.56 | $1,091.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.27 / $277.87 / $931.67
| Facility | | $209.27 | $277.87 | $931.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.14 / $209.27 / $406.99
| Professional | | $123.14 | $209.27 | $406.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.27 / $277.87 / $931.67
| Facility | | $209.27 | $277.87 | $931.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $209.27 / $297.39
| Professional | | $129.47 | $209.27 | $297.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.78 / $161.66 / $334.01
| Professional | | $154.78 | $161.66 | $334.01 |