- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,202.26 / $3,090.30
| Professional | | $870.96 | $1,202.26 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,230.27 / $1,995.26
| Professional | | $933.25 | $1,230.27 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,479.11 / $2,570.40
| Professional | | $389.05 | $1,479.11 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,548.82 / $2,570.40
| Professional | | $1,000.00 | $1,548.82 | $2,570.40 |