- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,277.00 / $2,965.17 / $5,199.80
| Facility | | $1,277.00 | $2,965.17 | $5,199.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,421.73 / $2,965.17 / $3,690.90
| Professional | | $2,421.73 | $2,965.17 | $3,690.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,343.98 / $3,102.35 / $3,102.35
| Professional | | $2,343.98 | $3,102.35 | $3,102.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,914.08 / $4,099.79 / $5,081.39
| Professional | | $2,914.08 | $4,099.79 | $5,081.39 |
- 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
- $2,232.08 / $3,034.46 / $4,962.50
| Professional | | $2,232.08 | $3,034.46 | $4,962.50 |