- 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
- $1,822.50 / $2,494.16 / $3,543.60
| Professional | | $1,822.50 | $2,494.16 | $3,543.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,849.26 / $2,559.53 / $4,390.79
| Professional | | $1,849.26 | $2,559.53 | $4,390.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,559.52 / $3,272.98 / $4,274.10
| Professional | | $2,559.52 | $3,272.98 | $4,274.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,649.00 / $2,257.00 / $6,383.00
| Facility | | $1,649.00 | $2,257.00 | $6,383.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,603.36 / $2,325.88 / $4,431.92
| Professional | | $1,603.36 | $2,325.88 | $4,431.92 |