- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $774.75 / $774.75 / $774.75
| Facility | | $774.75 | $774.75 | $774.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.75 / $774.75 / $774.75
| Professional | | $774.75 | $774.75 | $774.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.42 / $793.42 / $793.42
| Professional | | $793.42 | $793.42 | $793.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,187.08 / $1,499.43 / $3,023.03
| Facility | | $1,187.08 | $1,499.43 | $3,023.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.86 / $777.86 / $777.86
| Professional | | $777.86 | $777.86 | $777.86 |