- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,866.05 / $4,866.05 / $4,866.05
| Facility | | $4,866.05 | $4,866.05 | $4,866.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.39 / $626.24 / $693.94
| Professional | | $592.39 | $626.24 | $693.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $846.27 / $996.74 / $1,083.23
| Facility | | $846.27 | $996.74 | $1,083.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.70 / $634.70 / $1,034.05
| Professional | | $634.70 | $634.70 | $1,034.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,246.12 / $2,246.12 / $2,246.12
| Facility | | $2,246.12 | $2,246.12 | $2,246.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.20 / $1,123.03 / $2,288.15
| Professional | | $420.20 | $1,123.03 | $2,288.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.43 / $507.76 / $1,220.58
| Professional | | $355.43 | $507.76 | $1,220.58 |