- 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
- $407.38 / $794.33 / $1,819.70
| Professional | | $407.38 | $794.33 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $549.54 / $1,071.52
| Professional | | $467.74 | $549.54 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $851.14 / $1,348.96
| Professional | | $660.69 | $851.14 | $1,348.96 |
- 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
- $616.60 / $812.83 / $1,412.54
| Professional | | $616.60 | $812.83 | $1,412.54 |