- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $2,691.53 / $4,365.16
| Facility | | $933.25 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,659.59 / $2,951.21
| Professional | | $1,380.38 | $1,659.59 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,137.96 / $2,630.27
| Professional | | $1,819.70 | $2,137.96 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $1,380.38 / $1,380.38
| Facility | | $39.81 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $812.83 / $2,570.40
| Facility | | $489.78 | $812.83 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,041.74 / $3,548.13
| Professional | | $1,230.27 | $2,041.74 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $5,754.40 / $12,302.69
| Facility | | $1,122.02 | $5,754.40 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,659.59 / $2,884.03
| Professional | | $1,288.25 | $1,659.59 | $2,884.03 |