- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $5,011.87
| Facility | | $1,584.89 | $2,089.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,778.28 / $1,862.09
| Professional | | $1,698.24 | $1,778.28 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,467.37 / $4,466.84
| Facility | | $1,513.56 | $3,467.37 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $3,801.89 / $5,128.61
| Professional | | $741.31 | $3,801.89 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $1,288.25 / $2,041.74
| Facility | | $199.53 | $1,288.25 | $2,041.74 |