- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,142.06 / $2,089.96 / $2,318.38
| Facility | | $1,142.06 | $2,089.96 | $2,318.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.23 / $2,089.96 / $2,318.38
| Professional | | $902.23 | $2,089.96 | $2,318.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,142.06 / $1,142.06 / $1,142.06
| Facility | | $1,142.06 | $1,142.06 | $1,142.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.06 / $1,142.06 / $1,142.06
| Professional | | $1,142.06 | $1,142.06 | $1,142.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $42.50
| Professional | | $17.00 | $20.00 | $42.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.67 / $685.24 / $1,949.46
| Professional | | $479.67 | $685.24 | $1,949.46 |