- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Professional | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $4,677.35
| Facility | | $1,230.27 | $1,862.09 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $3,162.28
| Facility | | $1,737.80 | $1,737.80 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,041.74 / $2,754.23
| Facility | | $1,995.26 | $2,041.74 | $2,754.23 |