- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.55 / $63.10 / $676.08
| Professional | | $9.55 | $63.10 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.98 / $446.68 / $537.03
| Facility | | $194.98 | $446.68 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $660.69 / $1,000.00
| Facility | | $407.38 | $660.69 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $691.83 / $831.76
| Facility | | $389.05 | $691.83 | $831.76 |