- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $713.30 / $713.30 / $1,043.85
| Facility | | $713.30 | $713.30 | $1,043.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.30 / $1,043.85 / $1,174.33
| Professional | | $713.30 | $1,043.85 | $1,174.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.17 / $37.17 / $37.17
| Professional | | $37.17 | $37.17 | $37.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $739.40 / $739.40 / $739.40
| Facility | | $739.40 | $739.40 | $739.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $739.40 / $739.40 / $739.40
| Professional | | $739.40 | $739.40 | $739.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $17.00 / $20.00
| Professional | | $17.00 | $17.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.20 / $85.80 / $182.36
| Professional | | $57.20 | $85.80 | $182.36 |