- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $2,511.89 / $6,760.83
| Facility | | $229.09 | $2,511.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $977.24 / $1,548.82
| Professional | | $144.54 | $977.24 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,412.54 / $2,187.76
| Facility | | $346.74 | $1,412.54 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $1,698.24 / $2,187.76
| Professional | | $363.08 | $1,698.24 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $3,548.13
| Facility | | $1,148.15 | $1,621.81 | $3,548.13 |