- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,202.26 / $3,019.95
| Professional | | $741.31 | $1,202.26 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $933.25 / $1,819.70
| Professional | | $794.33 | $933.25 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,445.44 / $2,187.76
| Professional | | $1,000.00 | $1,445.44 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $10,000.00
| Facility | | $2,818.38 | $5,128.61 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,380.38 / $2,089.30
| Professional | | $891.25 | $1,380.38 | $2,089.30 |