- 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
- $173.78 / $645.65 / $1,548.82
| Professional | | $173.78 | $645.65 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,584.89 / $1,949.84
| Facility | | $912.01 | $1,584.89 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,995.26 / $4,786.30
| Facility | | $602.56 | $1,995.26 | $4,786.30 |