- 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
- $1,412.54 / $1,621.81 / $3,090.30
| Professional | | $1,412.54 | $1,621.81 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,862.09 / $3,019.95
| Professional | | $1,479.11 | $1,862.09 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $2,137.96 / $3,890.45
| Professional | | $616.60 | $2,137.96 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $2,238.72 / $6,606.93
| Facility | | $575.44 | $2,238.72 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,862.09 / $3,311.31
| Professional | | $1,380.38 | $1,862.09 | $3,311.31 |