- 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
- $925.25 / $1,367.15 / $1,453.83
| Professional | | $925.25 | $1,367.15 | $1,453.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,209.96 / $1,423.48 / $2,378.55
| Professional | | $1,209.96 | $1,423.48 | $2,378.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.00 / $1,374.55 / $2,593.82
| Professional | | $750.00 | $1,374.55 | $2,593.82 |
- 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
- $1,043.88 / $1,757.07 / $2,695.67
| Professional | | $1,043.88 | $1,757.07 | $2,695.67 |