- 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
- $557.19 / $732.54 / $1,129.32
| Professional | | $557.19 | $732.54 | $1,129.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.55 / $724.40 / $1,441.26
| Professional | | $596.55 | $724.40 | $1,441.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.64 / $1,057.50 / $1,417.95
| Professional | | $683.64 | $1,057.50 | $1,417.95 |
- 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
- $511.52 / $982.87 / $1,599.79
| Professional | | $511.52 | $982.87 | $1,599.79 |