- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,981.07
| Facility | | $2,089.30 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $588.84 / $1,584.89
| Professional | | $512.86 | $588.84 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $588.84 / $977.24
| Professional | | $501.19 | $588.84 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $851.14 / $1,202.26
| Professional | | $660.69 | $851.14 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $10,000.00
| Facility | | $2,818.38 | $5,128.61 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $691.83 / $1,288.25
| Professional | | $501.19 | $691.83 | $1,288.25 |