- 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
- $177.46 / $253.14 / $352.53
| Professional | | $177.46 | $253.14 | $352.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.36 / $248.25 / $437.62
| Professional | | $179.36 | $248.25 | $437.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.28 / $330.96 / $424.23
| Professional | | $250.28 | $330.96 | $424.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.67 / $282.25 / $452.01
| Professional | | $168.67 | $282.25 | $452.01 |