- 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
- $821.15 / $1,572.38 / $1,640.00
| Professional | | $821.15 | $1,572.38 | $1,640.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.74 / $1,518.52 / $2,478.46
| Professional | | $1,290.74 | $1,518.52 | $2,478.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.24 / $1,755.69 / $2,892.15
| Professional | | $1,292.24 | $1,755.69 | $2,892.15 |
- 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
- $1,299.30 / $1,650.98 / $2,769.52
| Professional | | $1,299.30 | $1,650.98 | $2,769.52 |