- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,845.03 / $1,845.03 / $1,845.03
| Facility | | $1,845.03 | $1,845.03 | $1,845.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,749.59 / $1,988.18
| Professional | | $1,590.54 | $1,749.59 | $1,988.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.23 / $2,159.67 / $4,410.30
| Facility | | $202.23 | $2,159.67 | $4,410.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,590.54
| Professional | | $1,590.54 | $1,590.54 | $1,590.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,574.63 / $1,749.59 / $1,749.59
| Professional | | $1,574.63 | $1,749.59 | $1,749.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,590.54
| Professional | | $1,590.54 | $1,590.54 | $1,590.54 |