- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $305.98 / $515.54 / $3,140.00
| Facility | | $305.98 | $515.54 | $3,140.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.06 / $200.60 / $225.01
| Professional | | $119.06 | $200.60 | $225.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.94 / $230.00 / $329.40
| Professional | | $134.94 | $230.00 | $329.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,425.73 / $1,425.73 / $2,724.54
| Facility | | $1,425.73 | $1,425.73 | $2,724.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.06 / $297.99 / $489.24
| Professional | | $211.06 | $297.99 | $489.24 |