- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $177.83
| Facility | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $190.55 / $295.12
| Professional | | $162.18 | $190.55 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $263.03 / $501.19
| Facility | | $263.03 | $263.03 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $478.63 / $794.33
| Professional | | $117.49 | $478.63 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,122.02
| Facility | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.20 / $144.54 / $269.15
| Professional | | $91.20 | $144.54 | $269.15 |