- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.73 / $2,778.87 / $3,955.04
| Facility | | $2,090.73 | $2,778.87 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.79 / $151.12 / $180.94
| Professional | | $109.79 | $151.12 | $180.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.02 / $156.49 / $255.70
| Professional | | $133.02 | $156.49 | $255.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.74 / $212.32 / $318.22
| Professional | | $180.74 | $212.32 | $318.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.43 / $249.67 / $367.46
| Professional | | $137.43 | $249.67 | $367.46 |