- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,235.94 / $4,365.16
| Facility | | $891.25 | $3,235.94 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $257.04 / $3,715.35
| Professional | | $257.04 | $257.04 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $912.01 / $1,513.56
| Facility | | $537.03 | $912.01 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $1,000.00 / $2,187.76
| Facility | | $338.84 | $1,000.00 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $25.70 / $26.30
| Professional | | $25.70 | $25.70 | $26.30 |