- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $728.67 / $728.67 / $3,955.04
| Facility | | $728.67 | $728.67 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.39 / $164.63 / $233.54
| Professional | | $105.39 | $164.63 | $233.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.79 / $227.91 / $315.08
| Professional | | $145.79 | $227.91 | $315.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.33 / $243.75 / $383.60
| Professional | | $148.33 | $243.75 | $383.60 |
- 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
- $162.88 / $265.89 / $473.32
| Professional | | $162.88 | $265.89 | $473.32 |