- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $812.83 / $2,137.96
| Professional | | $707.95 | $812.83 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $794.33 / $1,318.26
| Professional | | $707.95 | $794.33 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,096.48 / $1,621.81
| Professional | | $891.25 | $1,096.48 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $10,000.00
| Facility | | $2,818.38 | $5,128.61 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $933.25 / $1,737.80
| Professional | | $660.69 | $933.25 | $1,737.80 |