- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.38 / $165.57 / $3,469.89
| Facility | | $110.38 | $165.57 | $3,469.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $131.35
| Professional | | $108.47 | $108.47 | $131.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.47 / $119.32 / $162.71
| Facility | | $108.47 | $119.32 | $162.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $251.48
| Professional | | $108.47 | $108.47 | $251.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $163.28 / $163.28
| Facility | | $102.33 | $163.28 | $163.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $108.47 / $112.56
| Professional | | $108.47 | $108.47 | $112.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $743.95 / $743.95 / $743.95
| Facility | | $743.95 | $743.95 | $743.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $120.75 / $442.44
| Professional | | $108.47 | $120.75 | $442.44 |