- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,981.07 / $3,981.07
| Facility | | $3,715.35 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $354.81 / $831.76
| Professional | | $181.97 | $354.81 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $275.42 / $489.78
| Professional | | $234.42 | $275.42 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $426.58 / $602.56
| Professional | | $288.40 | $426.58 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $389.05 / $630.96
| Professional | | $302.00 | $389.05 | $630.96 |