- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $563.24 / $2,480.05 / $7,118.75
| Facility | | $563.24 | $2,480.05 | $7,118.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.32 / $402.32 / $639.09
| Professional | | $402.32 | $402.32 | $639.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.93 / $1,054.93 / $1,054.93
| Professional | | $1,054.93 | $1,054.93 | $1,054.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $104.42 / $1,874.50
| Facility | | $64.00 | $104.42 | $1,874.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,666.22 / $1,666.22 / $1,666.22
| Professional | | $1,666.22 | $1,666.22 | $1,666.22 |