- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $817.27 / $817.27 / $817.27
| Facility | | $817.27 | $817.27 | $817.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.00 / $617.41 / $817.27
| Professional | | $15.00 | $617.41 | $817.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.49 / $1,465.43 / $2,089.94
| Facility | | $1,167.49 | $1,465.43 | $2,089.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.70 / $1,080.70 / $1,080.70
| Professional | | $1,080.70 | $1,080.70 | $1,080.70 |