- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $333.56 / $475.55 / $1,700.00
| Facility | | $333.56 | $475.55 | $1,700.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.56 / $358.55 / $527.61
| Professional | | $333.56 | $358.55 | $527.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $591.78 / $591.78 / $591.78
| Facility | | $591.78 | $591.78 | $591.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.55 / $504.16 / $1,266.02
| Professional | | $333.55 | $504.16 | $1,266.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.41 / $565.52 / $746.03
| Professional | | $393.41 | $565.52 | $746.03 |