- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $5,011.87 / $8,317.64
| Facility | | $1,047.13 | $5,011.87 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $616.60 / $1,148.15
| Professional | | $407.38 | $616.60 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $562.34 / $812.83
| Professional | | $416.87 | $562.34 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Facility | | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $512.86 / $812.83
| Professional | | $398.11 | $512.86 | $812.83 |