- 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
- $954.99 / $1,548.82 / $3,981.07
| Professional | | $954.99 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $2,344.23
| Professional | | $1,023.29 | $1,380.38 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,698.24 / $2,951.21
| Professional | | $537.03 | $1,698.24 | $2,951.21 |
- 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
- $1,258.93 / $1,737.80 / $3,090.30
| Professional | | $1,258.93 | $1,737.80 | $3,090.30 |