- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,406.19 / $2,727.02 / $3,499.92
| Facility | | $2,406.19 | $2,727.02 | $3,499.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,499.92 / $3,499.92 / $3,499.92
| Professional | | $3,499.92 | $3,499.92 | $3,499.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,748.63 / $3,295.76 / $3,645.75
| Professional | | $2,748.63 | $3,295.76 | $3,645.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,208.26 / $3,499.92 / $4,083.24
| Professional | | $3,208.26 | $3,499.92 | $4,083.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,916.60 / $3,499.92 / $4,374.89
| Professional | | $2,916.60 | $3,499.92 | $4,374.89 |