- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $4,803.39 / $6,907.00
| Facility | | $3,140.00 | $4,803.39 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.83 / $153.71 / $168.40
| Professional | | $67.83 | $153.71 | $168.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.12 / $122.68 / $241.20
| Professional | | $74.12 | $122.68 | $241.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $998.06 / $998.06 / $998.06
| Facility | | $998.06 | $998.06 | $998.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.13 / $228.07 / $354.78
| Professional | | $154.13 | $228.07 | $354.78 |