- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.45 / $510.45 / $510.45
| Facility | | $510.45 | $510.45 | $510.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.45 / $510.45 / $510.45
| Professional | | $510.45 | $510.45 | $510.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.00 / $513.00 / $654.65
| Professional | | $513.00 | $513.00 | $654.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.69 / $506.69 / $506.69
| Professional | | $506.69 | $506.69 | $506.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.48 / $622.48 / $1,901.02
| Professional | | $622.48 | $622.48 | $1,901.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.51 / $477.77 / $726.78
| Professional | | $318.51 | $477.77 | $726.78 |