- 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
- $633.47 / $1,196.99 / $1,254.99
| Professional | | $633.47 | $1,196.99 | $1,254.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.78 / $1,262.08 / $1,906.34
| Professional | | $1,072.78 | $1,262.08 | $1,906.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.78 / $1,418.83 / $2,222.92
| Professional | | $977.78 | $1,418.83 | $2,222.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,685.00 / $8,200.00 / $27,485.00
| Facility | | $4,685.00 | $8,200.00 | $27,485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.86 / $1,387.87 / $2,121.27
| Professional | | $1,082.86 | $1,387.87 | $2,121.27 |