- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.61 / $1,769.11 / $1,769.11
| Professional | | $241.61 | $1,769.11 | $1,769.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $352.55 / $504.05 / $504.05
| Facility | | $352.55 | $504.05 | $504.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.55 / $409.90 / $504.05
| Professional | | $352.55 | $409.90 | $504.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $256.39 / $480.05 / $504.05
| Facility | | $256.39 | $480.05 | $504.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.55 / $378.32 / $536.90
| Professional | | $352.55 | $378.32 | $536.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.36 / $229.42 / $351.08
| Professional | | $207.36 | $229.42 | $351.08 |