- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,073.80
| Facility | | $3,981.07 | $3,981.07 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,380.38 / $2,570.40
| Professional | | $1,122.02 | $1,380.38 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,698.24 / $2,511.89
| Professional | | $1,258.93 | $1,698.24 | $2,511.89 |
- 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 / $1,621.81 / $3,235.94
| Professional | | $616.60 | $1,621.81 | $3,235.94 |
- 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
- $1,096.48 / $1,513.56 / $2,818.38
| Professional | | $1,096.48 | $1,513.56 | $2,818.38 |