- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $466.42 / $466.42 / $466.42
| Facility | | $466.42 | $466.42 | $466.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.42 / $466.42 / $466.42
| Professional | | $466.42 | $466.42 | $466.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $733.41 / $1,271.79 / $1,548.65
| Facility | | $733.41 | $1,271.79 | $1,548.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,072.52 / $1,266.30 / $2,591.17
| Facility | | $1,072.52 | $1,266.30 | $2,591.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $395.98 / $510.86 / $866.23
| Facility | | $395.98 | $510.86 | $866.23 |