- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.28 / $358.28 / $358.28
| Facility | | $358.28 | $358.28 | $358.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.28 / $358.28 / $358.28
| Professional | | $358.28 | $358.28 | $358.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.00 / $360.00 / $459.49
| Professional | | $360.00 | $360.00 | $459.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.61 / $306.61 / $306.61
| Professional | | $306.61 | $306.61 | $306.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.91 / $436.91 / $1,334.30
| Professional | | $436.91 | $436.91 | $1,334.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.56 / $335.33 / $475.06
| Professional | | $223.56 | $335.33 | $475.06 |