- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.76 / $7,838.38 / $7,838.38
| Facility | | $141.76 | $7,838.38 | $7,838.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.27 / $169.58 / $169.58
| Professional | | $140.27 | $169.58 | $169.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.47 / $161.47 / $215.04
| Professional | | $161.47 | $161.47 | $215.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.00 / $171.17 / $1,500.00
| Professional | | $85.00 | $171.17 | $1,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.02 / $175.12 / $215.00
| Facility | | $172.02 | $175.12 | $215.00 |