- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $2,454.71
| Professional | | $1,584.89 | $1,905.46 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $245.47
| Professional | | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $1,584.89 / $1,862.09
| Professional | | $251.19 | $1,584.89 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $1,380.38 / $2,454.71
| Facility | | $177.83 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,819.70 / $3,311.31
| Professional | | $1,047.13 | $1,819.70 | $3,311.31 |