- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,267.82 / $1,267.82 / $1,267.82
| Facility | | $1,267.82 | $1,267.82 | $1,267.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.82 / $1,267.82 / $1,267.82
| Professional | | $1,267.82 | $1,267.82 | $1,267.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $1,275.00
| Professional | | $1,275.00 | $1,275.00 | $1,275.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.98 / $1,084.98 / $1,084.98
| Professional | | $1,084.98 | $1,084.98 | $1,084.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.08 / $1,546.08 / $4,721.62
| Professional | | $1,546.08 | $1,546.08 | $4,721.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $791.10 / $1,186.65 / $1,681.09
| Professional | | $791.10 | $1,186.65 | $1,681.09 |