- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $370.22 / $425.00 / $1,242.76
| Facility | | $370.22 | $425.00 | $1,242.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $425.00 / $425.00
| Professional | | $318.75 | $425.00 | $425.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $659.16 / $659.16 / $659.16
| Facility | | $659.16 | $659.16 | $659.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,940.81 / $1,940.81 / $1,940.81
| Professional | | $1,940.81 | $1,940.81 | $1,940.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $727.96 / $727.96 / $727.96
| Facility | | $727.96 | $727.96 | $727.96 |