- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $578.91 / $1,510.20 / $1,857.56
| Facility | | $578.91 | $1,510.20 | $1,857.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.31 / $427.89 / $503.40
| Professional | | $342.31 | $427.89 | $503.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $28.88 / $1,510.20 / $2,732.96
| Facility | | $28.88 | $1,510.20 | $2,732.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.54 / $28.88 / $260.76
| Professional | | $24.54 | $28.88 | $260.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.40 / $629.25 / $11,093.70
| Facility | | $503.40 | $629.25 | $11,093.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.40 / $553.74 / $679.59
| Professional | | $503.40 | $553.74 | $679.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.20 / $951.26 / $1,962.74
| Facility | | $327.20 | $951.26 | $1,962.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.20 / $616.54 / $722.75
| Professional | | $578.20 | $616.54 | $722.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.43 / $302.04 / $503.40
| Professional | | $211.43 | $302.04 | $503.40 |