- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,159.42 / $5,750.14 / $6,318.84
| Facility | | $3,159.42 | $5,750.14 | $6,318.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $5,750.14 / $6,318.84
| Professional | | $2,495.94 | $5,750.14 | $6,318.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,107.25 / $4,265.22 / $4,265.22
| Facility | | $4,107.25 | $4,265.22 | $4,265.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,843.48 / $2,843.48 / $3,159.42
| Facility | | $2,843.48 | $2,843.48 | $3,159.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,895.65 / $6,318.84
| Professional | | $1,326.96 | $1,895.65 | $6,318.84 |