- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $305.57 / $345.50 / $1,112.28
| Facility | | $305.57 | $345.50 | $1,112.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.57 / $305.57 / $321.87
| Professional | | $305.57 | $305.57 | $321.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.86 / $537.80 / $802.64
| Professional | | $211.86 | $537.80 | $802.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $278.29 / $877.60 / $1,454.44
| Facility | | $278.29 | $877.60 | $1,454.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.43 / $407.43 / $1,963.81
| Professional | | $407.43 | $407.43 | $1,963.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $708.93 / $1,935.29 / $1,935.29
| Facility | | $708.93 | $1,935.29 | $1,935.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.00 / $2,029.00 / $3,055.73
| Professional | | $2,029.00 | $2,029.00 | $3,055.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.12 / $244.46 / $407.43
| Professional | | $171.12 | $244.46 | $407.43 |