- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $710.89 / $1,284.83 / $2,738.13
| Facility | | $710.89 | $1,284.83 | $2,738.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.78 / $507.78 / $910.21
| Professional | | $507.78 | $507.78 | $910.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.34 / $489.34 / $489.34
| Professional | | $489.34 | $489.34 | $489.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |