- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,830.33 / $5,063.00 / $7,631.00
| Facility | | $1,830.33 | $5,063.00 | $7,631.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.69 / $1,805.56 / $1,866.04
| Professional | | $1,392.69 | $1,805.56 | $1,866.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.88 / $1,890.08 / $3,656.54
| Professional | | $1,609.88 | $1,890.08 | $3,656.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,264.24 / $1,517.09 / $2,136.57
| Professional | | $1,264.24 | $1,517.09 | $2,136.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.00 / $4,826.00 / $7,889.00
| Facility | | $1,200.00 | $4,826.00 | $7,889.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,903.72 / $2,586.53 / $3,979.28
| Professional | | $1,903.72 | $2,586.53 | $3,979.28 |