- 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
- $69.53 / $85.45 / $94.00
| Professional | | $69.53 | $85.45 | $94.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.45 / $91.38 / $135.65
| Professional | | $76.45 | $91.38 | $135.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.56 / $81.62 / $158.78
| Professional | | $51.56 | $81.62 | $158.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,417.00 / $4,915.00
| Facility | | $540.00 | $1,417.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.13 / $83.56 / $121.43
| Professional | | $51.13 | $83.56 | $121.43 |