- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.68 / $1,933.90 / $2,401.02
| Professional | | $1,248.68 | $1,933.90 | $2,401.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,715.25 / $2,017.94 / $3,463.32
| Professional | | $1,715.25 | $2,017.94 | $3,463.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,591.63 / $2,346.71 / $4,065.30
| Professional | | $1,591.63 | $2,346.71 | $4,065.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $4,915.00 / $7,205.00
| Facility | | $1,649.00 | $4,915.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,986.92 / $2,395.17 / $3,487.27
| Professional | | $1,986.92 | $2,395.17 | $3,487.27 |