- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $769.68 / $769.68 / $769.68
| Facility | | $769.68 | $769.68 | $769.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.85 / $475.00 / $600.00
| Professional | | $132.85 | $475.00 | $600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.30 / $188.31 / $687.76
| Facility | | $140.30 | $188.31 | $687.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.05 / $173.34 / $304.72
| Facility | | $169.05 | $173.34 | $304.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.48 / $175.18 / $213.13
| Professional | | $102.48 | $175.18 | $213.13 |