- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $803.00 / $1,173.75 / $2,812.00
| Facility | | $803.00 | $1,173.75 | $2,812.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.83 / $1,152.91 / $1,239.13
| Professional | | $766.83 | $1,152.91 | $1,239.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,782.27 / $4,782.27 / $5,738.72
| Facility | | $4,782.27 | $4,782.27 | $5,738.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.18 / $1,166.27 / $1,166.27
| Professional | | $881.18 | $1,166.27 | $1,166.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,020.65 / $2,020.65 / $2,020.65
| Facility | | $2,020.65 | $2,020.65 | $2,020.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.14 / $1,380.54 / $1,642.93
| Professional | | $1,091.14 | $1,380.54 | $1,642.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $980.00 / $2,052.00 / $8,018.61
| Facility | | $980.00 | $2,052.00 | $8,018.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.74 / $955.11 / $1,686.78
| Professional | | $793.74 | $955.11 | $1,686.78 |