- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.72 / $1,751.72 / $1,751.72
| Facility | | $1,751.72 | $1,751.72 | $1,751.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.72 / $1,751.72 / $2,550.00
| Professional | | $1,751.72 | $1,751.72 | $2,550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,844.50 / $2,305.62
| Professional | | $1,350.00 | $1,844.50 | $2,305.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.52 / $237.52 / $2,375.14
| Facility | | $237.52 | $237.52 | $2,375.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.67 / $783.67 / $2,434.73
| Professional | | $783.67 | $783.67 | $2,434.73 |