- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,355.90 / $4,163.97
| Facility | | $1,277.00 | $2,355.90 | $4,163.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.27 / $2,355.90 / $2,803.52
| Professional | | $1,836.27 | $2,355.90 | $2,803.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,883.70 / $2,493.14 / $2,493.14
| Professional | | $1,883.70 | $2,493.14 | $2,493.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,334.10 / $3,208.98 / $4,034.40
| Professional | | $2,334.10 | $3,208.98 | $4,034.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,056.00 / $2,558.00
| Facility | | $375.00 | $1,056.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,833.82 / $2,590.29 / $3,940.02
| Professional | | $1,833.82 | $2,590.29 | $3,940.02 |