- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.35 / $2,334.57 / $2,334.57
| Facility | | $660.35 | $2,334.57 | $2,334.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.81 / $430.60 / $700.38
| Professional | | $373.81 | $430.60 | $700.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.98 / $440.98 / $440.98
| Professional | | $440.98 | $440.98 | $440.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.98 / $700.38 / $1,001.54
| Facility | | $440.98 | $700.38 | $1,001.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $430.60 / $700.38 / $1,001.54
| Facility | | $430.60 | $700.38 | $1,001.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.98 / $440.98 / $440.98
| Professional | | $440.98 | $440.98 | $440.98 |