- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $3,981.07
| Facility | | $3,019.95 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $275.42 / $478.63
| Professional | | $223.87 | $275.42 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $338.84 / $478.63
| Professional | | $251.19 | $338.84 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,570.40 / $2,570.40
| Facility | | $831.76 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $398.11 / $588.84
| Professional | | $204.17 | $398.11 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $3,548.13 / $7,413.10
| Facility | | $831.76 | $3,548.13 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $295.12 / $524.81
| Professional | | $223.87 | $295.12 | $524.81 |