- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,831.30 / $4,972.25
| Facility | | $1,277.00 | $2,831.30 | $4,972.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,235.52 / $2,831.30 / $3,529.22
| Professional | | $2,235.52 | $2,831.30 | $3,529.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,240.61 / $2,965.51 / $2,965.51
| Professional | | $2,240.61 | $2,965.51 | $2,965.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,772.00 / $3,925.62 / $4,855.56
| Professional | | $2,772.00 | $3,925.62 | $4,855.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,230.00 / $2,421.00
| Facility | | $375.00 | $1,230.00 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,169.44 / $2,702.15 / $4,706.43
| Professional | | $2,169.44 | $2,702.15 | $4,706.43 |