- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,393.94 / $1,393.94 / $2,221.59
| Facility | | $1,393.94 | $1,393.94 | $2,221.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.48 / $1,589.96 / $2,221.59
| Professional | | $1,308.48 | $1,589.96 | $2,221.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,927.51 / $1,927.51 / $1,927.51
| Facility | | $1,927.51 | $1,927.51 | $1,927.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,927.51 / $1,927.51 / $1,927.51
| Professional | | $1,927.51 | $1,927.51 | $1,927.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,618.14 / $1,618.14 / $1,618.14
| Facility | | $1,618.14 | $1,618.14 | $1,618.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.24 / $1,181.24 / $1,618.14
| Professional | | $1,181.24 | $1,181.24 | $1,618.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.56 / $1,180.84 / $1,852.34
| Professional | | $733.56 | $1,180.84 | $1,852.34 |