- 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
- $41.11 / $84.20 / $125.10
| Professional | | $41.11 | $84.20 | $125.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.62 / $93.21 / $159.83
| Professional | | $54.62 | $93.21 | $159.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.77 / $109.38 / $207.70
| Professional | | $57.77 | $109.38 | $207.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.00 / $139.63 / $216.42
| Professional | | $89.00 | $139.63 | $216.42 |