- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.48 / $1,093.29 / $1,093.29
| Professional | | $795.48 | $1,093.29 | $1,093.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $840.94 / $840.94 / $1,127.58
| Facility | | $840.94 | $840.94 | $1,127.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.08 / $1,586.25 / $1,982.81
| Professional | | $1,420.08 | $1,586.25 | $1,982.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.37 / $2,017.76 / $6,143.69
| Facility | | $116.37 | $2,017.76 | $6,143.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.51 / $927.01 / $1,030.99
| Professional | | $463.51 | $927.01 | $1,030.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.31 / $130.26 / $130.26
| Facility | | $108.31 | $130.26 | $130.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.63 / $155.97 / $297.67
| Professional | | $127.63 | $155.97 | $297.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.16 / $671.99 / $1,030.99
| Professional | | $462.16 | $671.99 | $1,030.99 |