- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $930.73 / $930.73 / $930.73
| Facility | | $930.73 | $930.73 | $930.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.73 / $930.73 / $930.73
| Professional | | $930.73 | $930.73 | $930.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,269.51 / $1,269.51 / $1,554.53
| Professional | | $1,269.51 | $1,269.51 | $1,554.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.40 / $949.40 / $949.40
| Professional | | $949.40 | $949.40 | $949.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,478.14 / $1,478.14 / $4,514.14
| Professional | | $1,478.14 | $1,478.14 | $4,514.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.33 / $1,134.50 / $2,386.34
| Professional | | $756.33 | $1,134.50 | $2,386.34 |