- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,890.45 / $4,677.35
| Facility | | $3,235.94 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,090.30 / $4,897.79
| Professional | | $2,137.96 | $3,090.30 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Professional | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,265.80 / $4,466.84
| Professional | | $3,630.78 | $4,265.80 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,265.80 / $5,370.32
| Professional | | $3,981.07 | $4,265.80 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,890.45 / $5,888.44
| Professional | | $1,949.84 | $3,890.45 | $5,888.44 |