- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $1,047.13 / $4,466.84
| Facility | | $363.08 | $1,047.13 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $575.44 / $1,513.56
| Professional | | $251.19 | $575.44 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $588.84 / $1,000.00
| Professional | | $398.11 | $588.84 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $562.34 / $977.24
| Professional | | $389.05 | $562.34 | $977.24 |