- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Facility | | $1,640.93 | $1,640.93 | $1,640.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,788.61 / $1,805.02
| Professional | | $1,640.93 | $1,788.61 | $1,805.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.00 / $1,560.00 / $1,560.00
| Professional | | $1,326.00 | $1,560.00 | $1,560.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.05 / $1,548.05 / $1,548.05
| Facility | | $1,548.05 | $1,548.05 | $1,548.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $2,322.07 / $2,322.07
| Professional | | $1,640.93 | $2,322.07 | $2,322.07 |
- 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 |