- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,809.90 / $5,020.00
| Facility | | $1,277.00 | $2,809.90 | $5,020.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,209.59 / $2,833.93 / $3,443.86
| Professional | | $2,209.59 | $2,833.93 | $3,443.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.08 / $3,007.16 / $3,007.16
| Professional | | $2,272.08 | $3,007.16 | $3,007.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,810.75 / $4,089.58 / $4,860.00
| Professional | | $2,810.75 | $4,089.58 | $4,860.00 |
- 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
- $2,136.94 / $2,690.51 / $4,744.84
| Professional | | $2,136.94 | $2,690.51 | $4,744.84 |