- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $618.50 / $1,095.44 / $1,967.52
| Facility | | $618.50 | $1,095.44 | $1,967.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.06 / $798.38 / $798.38
| Professional | | $327.06 | $798.38 | $798.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.51 / $291.51 / $291.51
| Professional | | $291.51 | $291.51 | $291.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $798.38 / $862.25 / $1,775.86
| Facility | | $798.38 | $862.25 | $1,775.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.66 / $753.66 / $753.66
| Professional | | $753.66 | $753.66 | $753.66 |