- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,646.03 / $1,646.03 / $1,646.03
| Facility | | $1,646.03 | $1,646.03 | $1,646.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.62 / $588.62 / $1,646.03
| Professional | | $588.62 | $588.62 | $1,646.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.33 / $781.33 / $781.33
| Professional | | $781.33 | $781.33 | $781.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.62 / $588.62 / $753.43
| Facility | | $588.62 | $588.62 | $753.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $78.00 / $3,900.00
| Professional | | $30.00 | $78.00 | $3,900.00 |