- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.38 / $708.38 / $708.38
| Professional | | $708.38 | $708.38 | $708.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.62 / $297.62 / $297.62
| Facility | | $297.62 | $297.62 | $297.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.26 / $297.62 / $317.27
| Professional | | $217.26 | $297.62 | $317.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.41 / $153.41 / $153.41
| Facility | | $153.41 | $153.41 | $153.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.75 / $785.58 / $1,240.40
| Professional | | $570.75 | $785.58 | $1,240.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.41 / $153.41 / $297.62
| Facility | | $153.41 | $153.41 | $297.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.26 / $317.27 / $604.47
| Professional | | $217.26 | $317.27 | $604.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.67 / $790.71 / $2,062.71
| Professional | | $399.67 | $790.71 | $2,062.71 |