- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Professional | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $363.08 / $436.52
| Professional | | $295.12 | $363.08 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,949.84 / $2,398.83
| Facility | | $954.99 | $1,949.84 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,202.26 / $1,258.93
| Facility | | $1,023.29 | $1,202.26 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,230.27 / $1,513.56
| Facility | | $1,000.00 | $1,230.27 | $1,513.56 |