- 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
- $1,649.57 / $1,681.18 / $2,215.55
| Professional | | $1,649.57 | $1,681.18 | $2,215.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,708.96 / $2,010.54 / $3,185.46
| Professional | | $1,708.96 | $2,010.54 | $3,185.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $2,244.77 / $3,421.88
| Professional | | $300.00 | $2,244.77 | $3,421.88 |
- 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
- $1,651.84 / $2,346.38 / $3,609.42
| Professional | | $1,651.84 | $2,346.38 | $3,609.42 |