- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.83 / $317.83 / $317.83
| Professional | | $317.83 | $317.83 | $317.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.74 / $362.11 / $531.03
| Facility | | $142.74 | $362.11 | $531.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.50 / $689.50 / $689.50
| Professional | | $689.50 | $689.50 | $689.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.04 / $278.76 / $12,000.00
| Facility | | $253.04 | $278.76 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.00 / $1,587.96 / $1,587.96
| Professional | | $1,182.00 | $1,587.96 | $1,587.96 |