- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.38 / $41.38 / $41.38
| Professional | | $41.38 | $41.38 | $41.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,478.55 / $1,478.55 / $1,478.55
| Facility | | $1,478.55 | $1,478.55 | $1,478.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.55 / $1,478.55 / $1,478.55
| Professional | | $1,478.55 | $1,478.55 | $1,478.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,478.55 / $1,478.55 / $1,478.55
| Facility | | $1,478.55 | $1,478.55 | $1,478.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.68 / $1,364.66 / $2,080.32
| Professional | | $909.68 | $1,364.66 | $2,080.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.28 / $42.28 / $42.28
| Professional | | $42.28 | $42.28 | $42.28 |