- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,182.66 / $2,099.21 / $6,297.17
| Facility | | $1,182.66 | $2,099.21 | $6,297.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.58 / $985.55 / $6,297.17
| Professional | | $707.58 | $985.55 | $6,297.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $410.65 / $1,263.53 / $3,032.47
| Facility | | $410.65 | $1,263.53 | $3,032.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.38 / $66.38 / $654.50
| Professional | | $66.38 | $66.38 | $654.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.29 / $1,478.32 / $2,053.23
| Facility | | $821.29 | $1,478.32 | $2,053.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,538.80 / $1,538.80 / $1,843.65
| Professional | | $1,538.80 | $1,538.80 | $1,843.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.53 / $1,263.53 / $1,326.71
| Professional | | $1,263.53 | $1,263.53 | $1,326.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,895.30 / $1,895.30 / $1,895.30
| Facility | | $1,895.30 | $1,895.30 | $1,895.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $530.67 / $1,326.71
| Professional | | $530.67 | $530.67 | $1,326.71 |