- 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
- $524.81 / $954.99 / $1,202.26
| Professional | | $524.81 | $954.99 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $758.58 / $1,318.26
| Professional | | $630.96 | $758.58 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,174.90 / $1,659.59
| Professional | | $758.58 | $1,174.90 | $1,659.59 |
- 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
- $812.83 / $1,096.48 / $1,698.24
| Professional | | $812.83 | $1,096.48 | $1,698.24 |