- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,747.00 / $2,747.00 / $2,747.00
| Facility | | $2,747.00 | $2,747.00 | $2,747.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.92 / $1,741.92 / $1,741.92
| Professional | | $1,741.92 | $1,741.92 | $1,741.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.18 / $1,274.22 / $1,526.66
| Professional | | $1,001.18 | $1,274.22 | $1,526.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.00 / $2,446.00 / $2,446.00
| Facility | | $2,446.00 | $2,446.00 | $2,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,217.16 / $2,955.77 / $3,224.50
| Professional | | $2,217.16 | $2,955.77 | $3,224.50 |