- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,162.28 / $3,801.89
| Facility | | $2,754.23 | $3,162.28 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,162.28 / $4,073.80
| Professional | | $2,290.87 | $3,162.28 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $389.05 / $8,511.38
| Facility | | $389.05 | $389.05 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $4,677.35
| Professional | | $1,995.26 | $2,691.53 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $3,548.13
| Facility | | $3,388.44 | $3,388.44 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $3,388.44 / $6,606.93
| Professional | | $398.11 | $3,388.44 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $489.78 / $3,090.30
| Facility | | $223.87 | $489.78 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,995.26 / $3,467.37
| Professional | | $1,380.38 | $1,995.26 | $3,467.37 |