- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.97 / $153.41 / $153.41
| Facility | | $98.97 | $153.41 | $153.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.32 / $153.41 / $164.95
| Professional | | $97.32 | $153.41 | $164.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.00 / $341.00 / $801.35
| Professional | | $341.00 | $341.00 | $801.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $406.32 / $978.66 / $978.66
| Facility | | $406.32 | $978.66 | $978.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.08 / $1,307.34 / $1,343.17
| Professional | | $1,254.08 | $1,307.34 | $1,343.17 |