- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.41 / $1,479.41 / $8,500.00
| Facility | | $1,479.41 | $1,479.41 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.39 / $1,479.41 / $1,479.41
| Professional | | $245.39 | $1,479.41 | $1,479.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $777.78 / $1,479.41 / $2,515.00
| Facility | | $777.78 | $1,479.41 | $2,515.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.84 / $704.69 / $993.83
| Professional | | $422.84 | $704.69 | $993.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.10 / $715.43 / $982.27
| Professional | | $415.10 | $715.43 | $982.27 |