- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.29 / $3,302.21 / $3,302.21
| Facility | | $241.29 | $3,302.21 | $3,302.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.48 / $291.48 / $862.16
| Professional | | $291.48 | $291.48 | $862.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.49 / $146.88 / $205.17
| Professional | | $144.49 | $146.88 | $205.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.12 / $190.73 / $190.73
| Professional | | $162.12 | $190.73 | $190.73 |