- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $380.19 / $4,897.79
| Professional | | $177.83 | $380.19 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $575.44 / $691.83
| Professional | | $380.19 | $575.44 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $346.74 / $436.52
| Professional | | $245.47 | $346.74 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $10,471.29
| Facility | | $2,630.27 | $2,754.23 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $398.11 / $660.69
| Professional | | $213.80 | $398.11 | $660.69 |