- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.01 / $102.01 / $301.50
| Facility | | $102.01 | $102.01 | $301.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.18 / $137.54 / $317.07
| Professional | | $81.18 | $137.54 | $317.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,319.60 / $2,319.60 / $2,505.98
| Facility | | $2,319.60 | $2,319.60 | $2,505.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.33 / $317.33 / $850.81
| Professional | | $317.33 | $317.33 | $850.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.48 / $209.68 / $590.71
| Professional | | $110.48 | $209.68 | $590.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.32 / $292.10 / $590.71
| Professional | | $116.32 | $292.10 | $590.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.70 / $377.68 / $1,044.27
| Professional | | $268.70 | $377.68 | $1,044.27 |