- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.94 / $953.05 / $1,521.82
| Facility | | $489.94 | $953.05 | $1,521.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $909.07 / $1,512.90 / $2,020.54
| Facility | | $909.07 | $1,512.90 | $2,020.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.55 / $307.55 / $307.55
| Professional | | $307.55 | $307.55 | $307.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,694.41 / $1,955.78 / $2,577.66
| Facility | | $1,694.41 | $1,955.78 | $2,577.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.92 / $47.92 / $47.92
| Professional | | $47.92 | $47.92 | $47.92 |