- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.44 / $215.44 / $215.44
| Professional | | $215.44 | $215.44 | $215.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.00 / $458.00 / $668.00
| Professional | | $382.00 | $458.00 | $668.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.87 / $356.37 / $473.52
| Professional | | $251.87 | $356.37 | $473.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.39 / $499.66 / $815.75
| Professional | | $290.39 | $499.66 | $815.75 |