- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $3,235.94
| Facility | | $2,344.23 | $2,344.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $2,344.23
| Professional | | $1,230.27 | $1,584.89 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $2,511.89
| Professional | | $1,659.59 | $1,659.59 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,479.11 / $3,467.37
| Facility | | $1,202.26 | $1,479.11 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,122.02 / $1,862.09
| Professional | | $776.25 | $1,122.02 | $1,862.09 |