- 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
- $1,366.43 / $2,361.87 / $2,603.06
| Professional | | $1,366.43 | $2,361.87 | $2,603.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,303.53 / $2,710.04 / $4,358.22
| Professional | | $2,303.53 | $2,710.04 | $4,358.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,127.84 / $3,101.48 / $4,793.60
| Professional | | $2,127.84 | $3,101.48 | $4,793.60 |
- 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
- $2,092.73 / $3,003.57 / $4,680.63
| Professional | | $2,092.73 | $3,003.57 | $4,680.63 |