- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $279.85 / $2,056.44 / $5,864.06
| Facility | | $279.85 | $2,056.44 | $5,864.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.85 / $279.85 / $322.39
| Professional | | $279.85 | $279.85 | $322.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.45 / $375.45 / $375.45
| Facility | | $375.45 | $375.45 | $375.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.45 / $375.45 / $375.45
| Professional | | $375.45 | $375.45 | $375.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $372.25 / $1,399.25 / $1,449.55
| Facility | | $372.25 | $1,399.25 | $1,449.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.85 / $279.85 / $816.60
| Professional | | $279.85 | $279.85 | $816.60 |