- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $2,137.96 / $4,570.88
| Facility | | $602.56 | $2,137.96 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $630.96 / $1,737.80
| Professional | | $316.23 | $630.96 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $1,659.59 / $4,073.80
| Professional | | $331.13 | $1,659.59 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $602.56 / $1,380.38
| Professional | | $346.74 | $602.56 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $794.33 / $1,318.26
| Professional | | $645.65 | $794.33 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $6,760.83 / $26,302.68
| Facility | | $1,023.29 | $6,760.83 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $616.60 / $1,174.90
| Professional | | $316.23 | $616.60 | $1,174.90 |