- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.35 / $1,789.24 / $1,789.24
| Professional | | $244.35 | $1,789.24 | $1,789.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $290.63 / $488.36 / $488.36
| Facility | | $290.63 | $488.36 | $488.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.63 / $397.14 / $488.36
| Professional | | $290.63 | $397.14 | $488.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $259.31 / $465.10 / $488.36
| Facility | | $259.31 | $465.10 | $488.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.63 / $366.53 / $533.37
| Professional | | $290.63 | $366.53 | $533.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.72 / $232.04 / $265.61
| Professional | | $209.72 | $232.04 | $265.61 |