- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,271.42 / $2,574.29 / $3,303.90
| Facility | | $2,271.42 | $2,574.29 | $3,303.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.43 / $455.43 / $455.43
| Professional | | $455.43 | $455.43 | $455.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,303.90 / $3,303.90 / $3,303.90
| Professional | | $3,303.90 | $3,303.90 | $3,303.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,594.67 / $3,111.17 / $3,441.56
| Professional | | $2,594.67 | $3,111.17 | $3,441.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,028.58 / $3,303.90 / $3,854.55
| Professional | | $3,028.58 | $3,303.90 | $3,854.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,753.25 / $3,303.90 / $4,129.88
| Professional | | $2,753.25 | $3,303.90 | $4,129.88 |