- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,955.04 / $5,496.04
| Facility | | $3,706.14 | $3,955.04 | $5,496.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.04 / $1,258.20 / $1,741.32
| Professional | | $1,239.04 | $1,258.20 | $1,741.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,293.58 / $1,521.86 / $2,489.35
| Professional | | $1,293.58 | $1,521.86 | $2,489.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $1,864.10 / $2,594.63
| Professional | | $300.00 | $1,864.10 | $2,594.63 |
- 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
- $1,165.28 / $1,798.51 / $2,540.19
| Professional | | $1,165.28 | $1,798.51 | $2,540.19 |