- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $763.20 / $1,038.96 / $3,787.06
| Facility | | $763.20 | $1,038.96 | $3,787.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.00 / $799.20 / $936.00
| Professional | | $540.00 | $799.20 | $936.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $779.62 / $1,406.09 / $2,215.58
| Facility | | $779.62 | $1,406.09 | $2,215.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $468.00 / $579.85 / $5,467.23
| Facility | | $468.00 | $579.85 | $5,467.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.60 / $827.24 / $1,034.05
| Professional | | $381.60 | $827.24 | $1,034.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $432.00 / $432.00 / $432.00
| Facility | | $432.00 | $432.00 | $432.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.00 / $360.00 / $1,080.00
| Professional | | $288.00 | $360.00 | $1,080.00 |