- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.90 / $100.00 / $147.91
| Facility | | $30.90 | $100.00 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $39.81 / $194.98
| Professional | | $39.81 | $39.81 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $426.58 / $1,023.29
| Facility | | $323.59 | $426.58 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $630.96
| Facility | | $338.84 | $338.84 | $630.96 |