- 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
- $1,905.46 / $2,089.30 / $5,128.61
| Professional | | $1,905.46 | $2,089.30 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $3,162.28
| Professional | | $1,548.82 | $2,041.74 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $2,691.53 / $4,168.69
| Professional | | $331.13 | $2,691.53 | $4,168.69 |
- 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 / $4,168.69
| Professional | | $1,737.80 | $2,454.71 | $4,168.69 |