- 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
- $1,501.02 / $2,622.56 / $2,861.04
| Professional | | $1,501.02 | $2,622.56 | $2,861.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,486.17 / $2,924.90 / $4,517.39
| Professional | | $2,486.17 | $2,924.90 | $4,517.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,341.64 / $3,386.52 / $5,250.40
| Professional | | $2,341.64 | $3,386.52 | $5,250.40 |
- 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
- $3,303.01 / $4,212.97 / $5,119.95
| Professional | | $3,303.01 | $4,212.97 | $5,119.95 |