- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.93 / $365.65 / $452.00
| Professional | | $225.93 | $365.65 | $452.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.33 / $443.91 / $718.10
| Professional | | $313.33 | $443.91 | $718.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.52 / $608.12 / $1,002.87
| Professional | | $358.52 | $608.12 | $1,002.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.83 / $625.49 / $1,075.59
| Professional | | $358.83 | $625.49 | $1,075.59 |