- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $3,575.00 / $4,601.00
| Facility | | $1,017.00 | $3,575.00 | $4,601.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.72 / $150.29 / $150.29
| Professional | | $141.72 | $150.29 | $150.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.63 / $319.68 / $319.68
| Professional | | $147.63 | $319.68 | $319.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.00 / $442.00 / $5,940.00
| Facility | | $165.00 | $442.00 | $5,940.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.80 / $130.72 / $396.58
| Professional | | $113.80 | $130.72 | $396.58 |