- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,893.66 / $2,893.66 / $3,124.78
| Facility | | $2,893.66 | $2,893.66 | $3,124.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.81 / $5.81 / $5.81
| Professional | | $5.81 | $5.81 | $5.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.07 / $85.65 / $96.80
| Professional | | $85.07 | $85.65 | $96.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $473.24 / $473.24 / $473.24
| Facility | | $473.24 | $473.24 | $473.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.75 / $533.75 / $533.75
| Professional | | $533.75 | $533.75 | $533.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.81 / $5.81 / $5.81
| Professional | | $5.81 | $5.81 | $5.81 |