- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.56 / $287.56 / $287.56
| Facility | | $287.56 | $287.56 | $287.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.56 / $287.56 / $287.56
| Professional | | $287.56 | $287.56 | $287.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,437.71 / $3,170.58 / $8,480.42
| Facility | | $1,437.71 | $3,170.58 | $8,480.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.56 / $1,348.87 / $3,958.00
| Facility | | $287.56 | $1,348.87 | $3,958.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,755.00 / $2,872.00 / $4,241.00
| Facility | | $1,755.00 | $2,872.00 | $4,241.00 |