- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $4,073.80 / $7,762.47
| Facility | | $1,258.93 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $2,238.72
| Professional | | $794.33 | $1,071.52 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $2,818.38 / $7,943.28
| Professional | | $912.01 | $2,818.38 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $2,754.23
| Professional | | $776.25 | $1,000.00 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,071.52 / $2,238.72
| Professional | | $912.01 | $1,071.52 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $16,218.10 / $26,915.35
| Facility | | $3,311.31 | $16,218.10 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $2,511.89
| Professional | | $645.65 | $912.01 | $2,511.89 |