- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.50 / $175.50 / $1,432.08
| Facility | | $175.50 | $175.50 | $1,432.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.50 / $175.50 / $182.52
| Professional | | $175.50 | $175.50 | $182.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.61 / $187.20 / $307.85
| Professional | | $156.61 | $187.20 | $307.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.25 / $395.46 / $851.11
| Facility | | $380.25 | $395.46 | $851.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.11 / $740.75 / $1,822.78
| Professional | | $141.11 | $740.75 | $1,822.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.10 / $475.65 / $475.65
| Professional | | $269.10 | $475.65 | $475.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.28 / $98.28 / $98.28
| Facility | | $98.28 | $98.28 | $98.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.28 / $140.40 / $372.06
| Professional | | $98.28 | $140.40 | $372.06 |