- 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
- $3,222.88 / $4,455.67 / $6,053.35
| Professional | | $3,222.88 | $4,455.67 | $6,053.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,384.34 / $6,334.52 / $9,786.91
| Professional | | $5,384.34 | $6,334.52 | $9,786.91 |
- 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
- $3,833.26 / $7,082.88 / $10,937.82
| Professional | | $3,833.26 | $7,082.88 | $10,937.82 |