- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $5,248.07 / $12,589.25
| Facility | | $1,288.25 | $5,248.07 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,047.13 / $2,041.74
| Professional | | $891.25 | $1,047.13 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $9,772.37 / $17,782.79
| Facility | | $3,388.44 | $9,772.37 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $2,041.74
| Professional | | $794.33 | $1,096.48 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,630.27 / $6,456.54
| Facility | | $645.65 | $2,630.27 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,288.25 / $2,754.23
| Professional | | $776.25 | $1,288.25 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $6,606.93 / $15,848.93
| Facility | | $1,778.28 | $6,606.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,122.02 / $2,041.74
| Professional | | $794.33 | $1,122.02 | $2,041.74 |