- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.00 / $3,140.00 / $6,907.00
| Facility | | $3,140.00 | $3,140.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.34 / $212.79 / $226.86
| Professional | | $193.34 | $212.79 | $226.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.00 / $418.00 / $418.00
| Facility | | $418.00 | $418.00 | $418.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.04 / $174.13 / $281.18
| Professional | | $167.04 | $174.13 | $281.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.44 / $181.99 / $431.04
| Professional | | $158.44 | $181.99 | $431.04 |