- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.62 / $588.62 / $588.62
| Facility | | $588.62 | $588.62 | $588.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.62 / $588.62 / $1,646.03
| Professional | | $588.62 | $588.62 | $1,646.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.33 / $781.33 / $781.33
| Professional | | $781.33 | $781.33 | $781.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $994.77 / $2,781.79 / $3,292.06
| Facility | | $994.77 | $2,781.79 | $3,292.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.42 / $1,475.42 / $1,475.42
| Professional | | $1,475.42 | $1,475.42 | $1,475.42 |