- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,487.60 / $1,487.60 / $1,487.60
| Facility | | $1,487.60 | $1,487.60 | $1,487.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.60 / $1,487.60 / $1,487.60
| Professional | | $1,487.60 | $1,487.60 | $1,487.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.00 / $1,496.00 / $1,907.85
| Professional | | $1,496.00 | $1,496.00 | $1,907.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.26 / $1,551.26 / $1,551.26
| Professional | | $1,551.26 | $1,551.26 | $1,551.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,814.09 / $1,814.09 / $5,540.12
| Professional | | $1,814.09 | $1,814.09 | $5,540.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.24 / $1,392.35 / $1,972.50
| Professional | | $928.24 | $1,392.35 | $1,972.50 |