- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,363.42 / $1,363.42 / $1,363.42
| Facility | | $1,363.42 | $1,363.42 | $1,363.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.42 / $1,363.42 / $1,363.42
| Professional | | $1,363.42 | $1,363.42 | $1,363.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.03 / $1,745.03 / $1,748.58
| Professional | | $1,745.03 | $1,745.03 | $1,748.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.50 / $1,260.50 / $1,260.50
| Professional | | $1,260.50 | $1,260.50 | $1,260.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,662.65 / $1,662.65 / $5,077.62
| Professional | | $1,662.65 | $1,662.65 | $5,077.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.75 / $1,276.11 / $2,181.13
| Professional | | $850.75 | $1,276.11 | $2,181.13 |