- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $691.83 / $1,862.09
| Professional | | $602.56 | $691.83 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $691.83 / $1,122.02
| Professional | | $602.56 | $691.83 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $977.24 / $1,412.54
| Professional | | $758.58 | $977.24 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $7,413.10 / $13,489.63
| Facility | | $3,715.35 | $7,413.10 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $812.83 / $1,479.11
| Professional | | $549.54 | $812.83 | $1,479.11 |