- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $379.70 / $379.70 / $1,044.00
| Facility | | $379.70 | $379.70 | $1,044.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.81 / $379.70 / $522.00
| Professional | | $180.81 | $379.70 | $522.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $390.00 / $452.40 / $1,076.40
| Facility | | $390.00 | $452.40 | $1,076.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.22 / $271.22 / $271.22
| Facility | | $271.22 | $271.22 | $271.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.57 / $180.81 / $301.35
| Professional | | $126.57 | $180.81 | $301.35 |