- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,466.84 / $4,466.84
| Facility | | $1,778.28 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $794.33 / $933.25
| Professional | | $741.31 | $794.33 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $933.25 / $1,096.48
| Professional | | $870.96 | $933.25 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,148.15 / $1,445.44
| Professional | | $1,000.00 | $1,148.15 | $1,445.44 |