- 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
- $2,126.44 / $2,321.71 / $2,517.15
| Professional | | $2,126.44 | $2,321.71 | $2,517.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,203.91 / $2,592.84 / $4,449.13
| Professional | | $2,203.91 | $2,592.84 | $4,449.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.00 / $2,973.06 / $4,332.35
| Professional | | $550.00 | $2,973.06 | $4,332.35 |
- 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
- $2,005.46 / $3,015.09 / $4,489.54
| Professional | | $2,005.46 | $3,015.09 | $4,489.54 |