- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,041.74 / $4,570.88
| Facility | | $758.58 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $275.42 / $416.87
| Professional | | $223.87 | $275.42 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,570.88 / $6,606.93
| Facility | | $2,454.71 | $4,570.88 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $331.13 / $398.11
| Professional | | $275.42 | $331.13 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $39.81
| Facility | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $323.59 / $446.68
| Professional | | $229.09 | $323.59 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,630.27 / $6,606.93
| Facility | | $831.76 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $302.00 / $478.63
| Professional | | $223.87 | $302.00 | $478.63 |