- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,600.12 / $1,600.12 / $2,500.19
| Facility | | $1,600.12 | $1,600.12 | $2,500.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,600.12 / $2,500.19 / $3,043.44
| Professional | | $1,600.12 | $2,500.19 | $3,043.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,212.63 / $2,212.63 / $2,212.63
| Facility | | $2,212.63 | $2,212.63 | $2,212.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,212.63 / $2,212.63 / $2,212.63
| Professional | | $2,212.63 | $2,212.63 | $2,212.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,784.15 / $1,784.15 / $1,784.15
| Facility | | $1,784.15 | $1,784.15 | $1,784.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.43 / $1,302.43 / $1,784.15
| Professional | | $1,302.43 | $1,302.43 | $1,784.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.65 / $1,424.47 / $2,195.07
| Professional | | $949.65 | $1,424.47 | $2,195.07 |