- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,011.87 / $8,128.31
| Facility | | $4,265.80 | $5,011.87 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $5,888.44 / $6,760.83
| Professional | | $3,090.30 | $5,888.44 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $12,882.50 / $12,882.50
| Professional | | $2,691.53 | $12,882.50 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $50.12 / $70.79
| Professional | | $50.12 | $50.12 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,760.83 / $6,760.83
| Facility | | $4,786.30 | $6,760.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $12,882.50 / $12,882.50
| Professional | | $6,456.54 | $12,882.50 | $12,882.50 |