- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.17 / $269.17 / $269.17
| Facility | | $269.17 | $269.17 | $269.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $441.74 / $576.36 / $1,123.85
| Facility | | $441.74 | $576.36 | $1,123.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.35 / $578.69 / $624.38
| Professional | | $289.35 | $578.69 | $624.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.37 / $691.32 / $864.14
| Professional | | $437.37 | $691.32 | $864.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.43 / $452.30 / $1,808.42
| Facility | | $228.43 | $452.30 | $1,808.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.43 / $228.43 / $761.44
| Professional | | $228.43 | $228.43 | $761.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.25 / $696.24 / $852.03
| Facility | | $457.25 | $696.24 | $852.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.25 / $829.67 / $993.68
| Professional | | $457.25 | $829.67 | $993.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.01 / $228.43 / $761.44
| Professional | | $217.01 | $228.43 | $761.44 |