- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $660.69 / $1,778.28
| Professional | | $575.44 | $660.69 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $660.69 / $1,096.48
| Professional | | $588.84 | $660.69 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,000.00 / $1,380.38
| Professional | | $741.31 | $1,000.00 | $1,380.38 |
- 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
- $562.34 / $812.83 / $1,445.44
| Professional | | $562.34 | $812.83 | $1,445.44 |