- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.09 / $318.22 / $8,738.84
| Facility | | $214.09 | $318.22 | $8,738.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $444.81
| Professional | | $318.22 | $318.22 | $444.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.85 / $303.00 / $303.00
| Facility | | $287.85 | $303.00 | $303.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.84 / $673.84 / $673.84
| Professional | | $673.84 | $673.84 | $673.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.88 / $321.39 / $894.20
| Facility | | $292.88 | $321.39 | $894.20 |