- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.01 / $1,539.67 / $1,633.79
| Professional | | $835.01 | $1,539.67 | $1,633.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.53 / $1,574.74 / $1,574.74
| Professional | | $1,338.53 | $1,574.74 | $1,574.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.37 / $2,253.34 / $4,330.87
| Professional | | $1,520.37 | $2,253.34 | $4,330.87 |