- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $4,897.79
| Facility | | $2,041.74 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $575.44 / $707.95
| Professional | | $223.87 | $575.44 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $2,041.74 / $4,897.79
| Facility | | $691.83 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $323.59 / $691.83
| Professional | | $257.04 | $323.59 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $4,073.80 / $6,309.57
| Facility | | $851.14 | $4,073.80 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $363.08 / $870.96
| Professional | | $288.40 | $363.08 | $870.96 |