- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,182.51 / $1,182.51 / $1,182.51
| Facility | | $1,182.51 | $1,182.51 | $1,182.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $722.53 / $1,182.51 / $1,182.51
| Professional | | $722.53 | $1,182.51 | $1,182.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.80 / $1,014.80 / $1,014.80
| Professional | | $1,014.80 | $1,014.80 | $1,014.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.11 / $109.54 / $279.41
| Professional | | $93.11 | $109.54 | $279.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.91 / $74.86 / $712.38
| Professional | | $49.91 | $74.86 | $712.38 |