- 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
- $536.63 / $647.76 / $903.43
| Professional | | $536.63 | $647.76 | $903.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.95 / $848.04 / $1,262.10
| Professional | | $620.95 | $848.04 | $1,262.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.71 / $905.73 / $1,637.87
| Professional | | $727.71 | $905.73 | $1,637.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,806.00 / $3,465.00 / $5,510.00
| Facility | | $1,806.00 | $3,465.00 | $5,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.83 / $1,021.54 / $1,475.15
| Professional | | $604.83 | $1,021.54 | $1,475.15 |