- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,498.12 / $1,498.12 / $1,498.12
| Facility | | $1,498.12 | $1,498.12 | $1,498.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,498.12 / $1,498.12 / $1,498.12
| Professional | | $1,498.12 | $1,498.12 | $1,498.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.00 / $1,507.00 / $1,921.35
| Professional | | $1,507.00 | $1,507.00 | $1,921.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.23 / $1,249.23 / $1,249.23
| Professional | | $1,249.23 | $1,249.23 | $1,249.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.92 / $1,826.92 / $5,579.31
| Professional | | $1,826.92 | $1,826.92 | $5,579.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.80 / $1,402.20 / $2,133.02
| Professional | | $934.80 | $1,402.20 | $2,133.02 |