- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.47 / $1,335.41 / $3,538.26
| Facility | | $836.47 | $1,335.41 | $3,538.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.60 / $49.76 / $60.00
| Professional | | $45.60 | $49.76 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $360.74
| Professional | | $360.74 | $360.74 | $360.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $920.12 / $1,032.19 / $1,341.85
| Facility | | $920.12 | $1,032.19 | $1,341.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |