- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.56 / $1,197.70 / $1,197.70
| Facility | | $177.56 | $1,197.70 | $1,197.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.30 / $236.30 / $236.30
| Professional | | $236.30 | $236.30 | $236.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.87 / $186.90 / $186.90
| Professional | | $158.87 | $186.90 | $186.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.44 / $174.44 / $174.44
| Professional | | $174.44 | $174.44 | $174.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.33 / $186.90 / $186.90
| Professional | | $171.33 | $186.90 | $186.90 |