- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,034.35 / $4,034.35 / $6,907.00
| Facility | | $4,034.35 | $4,034.35 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.22 / $1,073.89 / $2,699.79
| Professional | | $940.22 | $1,073.89 | $2,699.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.05 / $1,113.07 / $1,966.64
| Professional | | $946.05 | $1,113.07 | $1,966.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,783.00 / $2,783.00 / $2,783.00
| Facility | | $2,783.00 | $2,783.00 | $2,783.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.32 / $1,138.71 / $2,450.67
| Professional | | $885.32 | $1,138.71 | $2,450.67 |