- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.85 / $3,172.50 / $5,664.56
| Facility | | $1,053.85 | $3,172.50 | $5,664.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.87 / $1,029.07 / $1,070.64
| Professional | | $991.87 | $1,029.07 | $1,070.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.84 / $1,177.84 / $1,177.84
| Professional | | $1,177.84 | $1,177.84 | $1,177.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.85 / $1,053.85 / $1,053.85
| Facility | | $1,053.85 | $1,053.85 | $1,053.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.85 / $1,053.85 / $1,053.85
| Professional | | $1,053.85 | $1,053.85 | $1,053.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.54 / $1,033.20 / $1,118.08
| Professional | | $981.54 | $1,033.20 | $1,118.08 |