- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.00 / $4,235.59 / $7,119.04
| Facility | | $2,906.00 | $4,235.59 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.84 / $729.83 / $1,044.79
| Professional | | $112.84 | $729.83 | $1,044.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.83 / $838.32 / $1,460.80
| Facility | | $227.83 | $838.32 | $1,460.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $262.73 / $1,016.00 / $1,474.70
| Facility | | $262.73 | $1,016.00 | $1,474.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,026.00 / $1,623.00 / $2,126.00
| Facility | | $1,026.00 | $1,623.00 | $2,126.00 |