- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.52 / $210.52 / $210.52
| Facility | | $210.52 | $210.52 | $210.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.52 / $210.52 / $255.01
| Professional | | $210.52 | $210.52 | $255.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.60 / $452.32 / $696.32
| Professional | | $285.60 | $452.32 | $696.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.41 / $308.33 / $491.21
| Professional | | $229.41 | $308.33 | $491.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.40 / $271.08 / $467.14
| Facility | | $165.40 | $271.08 | $467.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.43 / $252.43 / $252.43
| Professional | | $252.43 | $252.43 | $252.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.55 / $306.66 / $596.88
| Professional | | $208.55 | $306.66 | $596.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $443.56 / $443.56 / $1,108.65
| Facility | | $443.56 | $443.56 | $1,108.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,787.70 / $2,805.00 / $2,805.00
| Professional | | $1,787.70 | $2,805.00 | $2,805.00 |