- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,019.95 / $4,365.16
| Facility | | $933.25 | $3,019.95 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,187.76 / $3,019.95
| Professional | | $1,148.15 | $2,187.76 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,011.87 / $7,585.78
| Facility | | $2,454.71 | $5,011.87 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,630.27 / $6,606.93
| Facility | | $831.76 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $3,801.89
| Professional | | $1,698.24 | $2,344.23 | $3,801.89 |