- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,935.29 / $4,162.60 / $10,013.70
| Facility | | $2,935.29 | $4,162.60 | $10,013.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,369.10 / $3,855.72 / $5,591.75
| Professional | | $2,369.10 | $3,855.72 | $5,591.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,386.17 / $3,805.62 / $7,884.81
| Facility | | $2,386.17 | $3,805.62 | $7,884.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,979.83 / $3,177.62 / $4,730.18
| Professional | | $1,979.83 | $3,177.62 | $4,730.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,155.87 / $3,155.87 / $3,155.87
| Facility | | $3,155.87 | $3,155.87 | $3,155.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,489.00 / $14,489.00 / $14,489.00
| Professional | | $14,489.00 | $14,489.00 | $14,489.00 |