- 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
- $1,862.09 / $2,290.87 / $5,888.44
| Professional | | $1,862.09 | $2,290.87 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,995.26 / $3,311.31
| Professional | | $1,479.11 | $1,995.26 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $2,398.83 / $3,981.07
| Professional | | $239.88 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,454.71 / $3,715.35
| Professional | | $1,737.80 | $2,454.71 | $3,715.35 |