- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,244.36
| Facility | | $3,235.94 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $112.20 / $288.40
| Professional | | $43.65 | $112.20 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $109.65 / $190.55
| Professional | | $38.90 | $109.65 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $97.72 / $190.55
| Professional | | $43.65 | $97.72 | $190.55 |