- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,842.49 / $3,842.49 / $3,842.49
| Facility | | $3,842.49 | $3,842.49 | $3,842.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,951.55 / $3,842.49 / $3,842.49
| Professional | | $1,951.55 | $3,842.49 | $3,842.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $4,546.46
| Facility | | $2,941.06 | $2,941.06 | $4,546.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $5,270.63
| Professional | | $2,146.96 | $2,146.96 | $5,270.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.82 / $2,280.46 / $3,139.43
| Professional | | $1,350.82 | $2,280.46 | $3,139.43 |