- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,863.22 / $3,409.69 / $3,782.34
| Facility | | $1,863.22 | $3,409.69 | $3,782.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,471.95 / $3,409.69 / $3,782.34
| Professional | | $1,471.95 | $3,409.69 | $3,782.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,059.51 / $2,059.51 / $2,059.51
| Facility | | $2,059.51 | $2,059.51 | $2,059.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,059.51 / $2,059.51 / $2,059.51
| Professional | | $2,059.51 | $2,059.51 | $2,059.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $42.50
| Professional | | $17.00 | $20.00 | $42.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.55 / $1,117.93 / $3,167.47
| Professional | | $782.55 | $1,117.93 | $3,167.47 |