- 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
- $869.96 / $1,632.83 / $1,720.45
| Professional | | $869.96 | $1,632.83 | $1,720.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.64 / $1,706.64 / $2,631.48
| Professional | | $1,450.64 | $1,706.64 | $2,631.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,346.02 / $1,935.06 / $3,021.05
| Professional | | $1,346.02 | $1,935.06 | $3,021.05 |
- 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
- $1,412.00 / $1,900.92 / $2,945.58
| Professional | | $1,412.00 | $1,900.92 | $2,945.58 |