- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.33 / $296.45 / $370.58
| Professional | | $203.33 | $296.45 | $370.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.81 / $407.81 / $407.81
| Facility | | $407.81 | $407.81 | $407.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.24 / $407.81 / $652.50
| Professional | | $47.24 | $407.81 | $652.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.83 / $254.89 / $2,978.91
| Facility | | $39.83 | $254.89 | $2,978.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.22 / $279.04 / $441.66
| Professional | | $186.22 | $279.04 | $441.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.22 / $279.33 / $401.83
| Professional | | $186.22 | $279.33 | $401.83 |