- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.49 / $1,347.47 / $1,347.47
| Professional | | $388.49 | $1,347.47 | $1,347.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.19 / $367.77 / $367.77
| Facility | | $243.19 | $367.77 | $367.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.19 / $299.08 / $367.77
| Professional | | $243.19 | $299.08 | $367.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.28 / $350.26 / $367.77
| Facility | | $195.28 | $350.26 | $367.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.19 / $276.02 / $402.80
| Professional | | $243.19 | $276.02 | $402.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.94 / $174.74 / $269.27
| Professional | | $157.94 | $174.74 | $269.27 |