- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,943.34 / $5,943.34 / $5,943.34
| Facility | | $5,943.34 | $5,943.34 | $5,943.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $1,901.86
| Professional | | $1,828.72 | $1,828.72 | $1,901.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,861.13 / $1,861.13 / $3,261.96
| Facility | | $1,861.13 | $1,861.13 | $3,261.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $1,828.72
| Professional | | $1,828.72 | $1,828.72 | $1,828.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.20 / $1,828.71 / $1,828.71
| Facility | | $1,725.20 | $1,828.71 | $1,828.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.71 / $1,828.71 / $1,828.71
| Professional | | $1,828.71 | $1,828.71 | $1,828.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.72 / $1,828.72 / $1,828.72
| Professional | | $1,828.72 | $1,828.72 | $1,828.72 |