- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,151.46 / $1,151.46 / $1,151.46
| Facility | | $1,151.46 | $1,151.46 | $1,151.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.07 / $1,151.46 / $1,151.46
| Professional | | $545.07 | $1,151.46 | $1,151.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.23 / $950.23 / $950.23
| Professional | | $950.23 | $950.23 | $950.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,057.34 / $1,057.34 / $1,500.51
| Facility | | $1,057.34 | $1,057.34 | $1,500.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.87 / $1,057.34 / $1,313.90
| Professional | | $771.87 | $1,057.34 | $1,313.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.08 / $636.11 / $958.22
| Professional | | $424.08 | $636.11 | $958.22 |