- 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
- $1,786.27 / $3,315.61 / $3,538.88
| Professional | | $1,786.27 | $3,315.61 | $3,538.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,955.43 / $3,476.98 / $5,336.54
| Professional | | $2,955.43 | $3,476.98 | $5,336.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,735.48 / $3,100.44 / $6,152.25
| Professional | | $2,735.48 | $3,100.44 | $6,152.25 |
- 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
- $2,538.66 / $3,565.22 / $5,928.31
| Professional | | $2,538.66 | $3,565.22 | $5,928.31 |