- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $335.50 / $862.26 / $3,949.00
| Facility | | $335.50 | $862.26 | $3,949.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.30 / $390.19 / $483.72
| Professional | | $301.30 | $390.19 | $483.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.83 / $467.19 / $720.59
| Professional | | $354.83 | $467.19 | $720.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,996.93 / $3,996.93 / $8,618.91
| Facility | | $3,996.93 | $3,996.93 | $8,618.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.43 / $544.09 / $1,045.44
| Professional | | $422.43 | $544.09 | $1,045.44 |