- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.67 / $342.04 / $342.04
| Facility | | $220.67 | $342.04 | $342.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.67 / $342.04 / $367.78
| Professional | | $220.67 | $342.04 | $367.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.00 / $697.00 / $1,637.95
| Professional | | $697.00 | $697.00 | $1,637.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $669.47 / $3,728.65 / $3,728.65
| Facility | | $669.47 | $3,728.65 | $3,728.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,390.37 / $2,390.37 / $3,160.73
| Professional | | $2,390.37 | $2,390.37 | $3,160.73 |