- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,919.03 / $5,150.72
| Facility | | $1,277.00 | $2,919.03 | $5,150.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.30 / $2,919.03 / $3,501.28
| Professional | | $2,398.30 | $2,919.03 | $3,501.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,329.69 / $3,083.43 / $3,083.43
| Professional | | $2,329.69 | $3,083.43 | $3,083.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,893.17 / $4,158.22 / $5,003.09
| Professional | | $2,893.17 | $4,158.22 | $5,003.09 |
- 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
- $2,199.12 / $3,028.77 / $4,886.04
| Professional | | $2,199.12 | $3,028.77 | $4,886.04 |