- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.15 / $231.15 / $231.15
| Facility | | $231.15 | $231.15 | $231.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.13 / $247.86 / $369.15
| Professional | | $155.13 | $247.86 | $369.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.38 / $216.38 / $216.38
| Professional | | $216.38 | $216.38 | $216.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.05 / $369.15 / $472.51
| Facility | | $211.05 | $369.15 | $472.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $2,000.00 / $3,900.00
| Professional | | $30.00 | $2,000.00 | $3,900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.57 / $254.57 / $254.57
| Professional | | $254.57 | $254.57 | $254.57 |