- 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
- $1,061.45 / $1,063.78 / $1,403.51
| Professional | | $1,061.45 | $1,063.78 | $1,403.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.88 / $1,253.98 / $2,078.21
| Professional | | $1,065.88 | $1,253.98 | $2,078.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,370.11 / $2,166.46
| Professional | | $300.00 | $1,370.11 | $2,166.46 |
- 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
- $1,043.00 / $1,328.04 / $2,021.03
| Professional | | $1,043.00 | $1,328.04 | $2,021.03 |