- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.62 / $1,300.00 / $3,500.00
| Facility | | $496.62 | $1,300.00 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.62 / $496.62 / $496.62
| Professional | | $496.62 | $496.62 | $496.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.17 / $4,321.93 / $9,173.53
| Facility | | $2,116.17 | $4,321.93 | $9,173.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,141.00 / $4,717.00 / $10,810.00
| Facility | | $1,141.00 | $4,717.00 | $10,810.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.28 / $273.70 / $504.98
| Professional | | $185.28 | $273.70 | $504.98 |