- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.83 / $4,815.52 / $4,815.52
| Professional | | $227.83 | $4,815.52 | $4,815.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $364.38 / $371.59 / $482.61
| Facility | | $364.38 | $371.59 | $482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.38 / $426.74 / $482.61
| Professional | | $364.38 | $426.74 | $482.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.40 / $371.59 / $682.78
| Facility | | $161.40 | $371.59 | $682.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.90 / $373.67 / $482.61
| Professional | | $242.90 | $373.67 | $482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.87 / $150.06 / $382.57
| Professional | | $148.87 | $150.06 | $382.57 |