- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.78 / $682.78 / $682.78
| Professional | | $682.78 | $682.78 | $682.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.56 / $166.56 / $166.56
| Professional | | $166.56 | $166.56 | $166.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $816.59 / $816.59 / $816.59
| Facility | | $816.59 | $816.59 | $816.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.43 / $816.59 / $2,021.76
| Professional | | $92.43 | $816.59 | $2,021.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.64 / $816.59 / $1,351.48
| Facility | | $108.64 | $816.59 | $1,351.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.43 / $816.59 / $2,021.76
| Professional | | $92.43 | $816.59 | $2,021.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.16 / $506.05 / $843.41
| Professional | | $475.16 | $506.05 | $843.41 |