- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Facility | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,326.37 / $2,326.37 / $2,326.37
| Professional | | $2,326.37 | $2,326.37 | $2,326.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,189.53 / $2,189.53 / $2,189.53
| Professional | | $2,189.53 | $2,189.53 | $2,189.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,554.44 / $2,554.44 / $2,554.44
| Facility | | $2,554.44 | $2,554.44 | $2,554.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.37 / $244.37 / $244.37
| Professional | | $244.37 | $244.37 | $244.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,325.69 / $2,654.57 / $3,284.29
| Professional | | $2,325.69 | $2,654.57 | $3,284.29 |