- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,903.48 / $1,903.48 / $1,903.48
| Facility | | $1,903.48 | $1,903.48 | $1,903.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,805.02 / $2,051.16
| Professional | | $1,640.93 | $1,805.02 | $2,051.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.34 / $766.49 / $1,952.69
| Facility | | $375.34 | $766.49 | $1,952.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Professional | | $1,640.93 | $1,640.93 | $1,640.93 |
- 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
- $1,624.52 / $1,805.02 / $1,805.02
| Professional | | $1,624.52 | $1,805.02 | $1,805.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Professional | | $1,640.93 | $1,640.93 | $1,640.93 |