- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,487.35 / $1,487.35 / $1,487.35
| Facility | | $1,487.35 | $1,487.35 | $1,487.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.07 / $1,487.35 / $1,487.35
| Professional | | $704.07 | $1,487.35 | $1,487.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.22 / $1,141.22 / $1,141.22
| Professional | | $1,141.22 | $1,141.22 | $1,141.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,014.49 / $1,014.49 / $1,560.91
| Facility | | $1,014.49 | $1,014.49 | $1,560.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.58 / $1,014.49 / $1,366.79
| Professional | | $740.58 | $1,014.49 | $1,366.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.18 / $630.26 / $1,015.86
| Professional | | $420.18 | $630.26 | $1,015.86 |