- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,476.20 / $1,476.20 / $1,476.20
| Facility | | $1,476.20 | $1,476.20 | $1,476.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,369.15 / $1,468.48 / $1,734.32
| Professional | | $1,369.15 | $1,468.48 | $1,734.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.88 / $1,698.88 / $1,698.88
| Professional | | $1,698.88 | $1,698.88 | $1,698.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,369.15 / $1,533.20 / $1,909.02
| Facility | | $1,369.15 | $1,533.20 | $1,909.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,000.00 / $3,000.00 / $3,000.00
| Professional | | $3,000.00 | $3,000.00 | $3,000.00 |