- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $886.52 / $886.52 / $886.52
| Facility | | $886.52 | $886.52 | $886.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.52 / $886.52 / $886.52
| Professional | | $886.52 | $886.52 | $886.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.00 / $1,161.00 / $1,480.69
| Professional | | $1,161.00 | $1,161.00 | $1,480.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.43 / $953.43 / $953.43
| Professional | | $953.43 | $953.43 | $953.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.93 / $1,407.93 / $4,299.71
| Professional | | $1,407.93 | $1,407.93 | $4,299.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.41 / $1,080.60 / $1,623.62
| Professional | | $720.41 | $1,080.60 | $1,623.62 |