- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.54 / $59.35 / $74.16
| Professional | | $39.54 | $59.35 | $74.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.87 / $73.47 / $112.41
| Professional | | $45.87 | $73.47 | $112.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.39 / $86.92 / $162.62
| Professional | | $54.39 | $86.92 | $162.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.00 / $92.11 / $142.44
| Professional | | $65.00 | $92.11 | $142.44 |