- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $471.82 / $471.82 / $471.82
| Facility | | $471.82 | $471.82 | $471.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $471.82 / $471.82 / $471.82
| Professional | | $471.82 | $471.82 | $471.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.00 / $475.00 / $475.00
| Professional | | $475.00 | $475.00 | $475.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.33 / $362.33 / $362.33
| Professional | | $362.33 | $362.33 | $362.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.37 / $575.37 / $1,757.15
| Professional | | $575.37 | $575.37 | $1,757.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.41 / $441.61 / $754.79
| Professional | | $294.41 | $441.61 | $754.79 |