- 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
- $46.72 / $92.53 / $124.59
| Professional | | $46.72 | $92.53 | $124.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.48 / $117.22 / $190.54
| Professional | | $72.48 | $117.22 | $190.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.20 / $140.66 / $232.05
| Professional | | $78.20 | $140.66 | $232.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.55 / $119.45 / $247.05
| Professional | | $97.55 | $119.45 | $247.05 |