- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.66 / $1,648.82 / $2,161.71
| Facility | | $314.66 | $1,648.82 | $2,161.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.66 / $314.66 / $314.66
| Professional | | $314.66 | $314.66 | $314.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $349.62 / $402.06 / $1,415.96
| Facility | | $349.62 | $402.06 | $1,415.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.62 / $370.09 / $436.54
| Professional | | $349.62 | $370.09 | $436.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.84 / $146.84 / $209.77
| Professional | | $146.84 | $146.84 | $209.77 |