- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $445.46 / $445.46 / $445.46
| Facility | | $445.46 | $445.46 | $445.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.05 / $341.92 / $445.46
| Professional | | $340.05 | $341.92 | $445.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.44 / $567.44 / $567.44
| Professional | | $567.44 | $567.44 | $567.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $341.92 / $525.11 / $1,000.01
| Facility | | $341.92 | $525.11 | $1,000.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,763.97 / $3,763.97 / $3,763.97
| Professional | | $3,763.97 | $3,763.97 | $3,763.97 |