- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,445.44
| Professional | | $1,230.27 | $1,230.27 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,698.24 / $1,698.24
| Professional | | $1,412.54 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,174.90
| Facility | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,737.80
| Professional | | $1,230.27 | $1,230.27 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,047.13 / $1,412.54
| Professional | | $125.89 | $1,047.13 | $1,412.54 |