- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $484.10 / $484.10 / $8,500.00
| Facility | | $484.10 | $484.10 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.27 / $484.10 / $520.91
| Professional | | $410.27 | $484.10 | $520.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.52 / $1,123.89 / $1,322.22
| Professional | | $1,006.52 | $1,123.89 | $1,322.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.44 / $1,267.54 / $1,688.36
| Professional | | $634.44 | $1,267.54 | $1,688.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $484.10 / $630.35 / $875.93
| Facility | | $484.10 | $630.35 | $875.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.17 / $888.08 / $1,257.26
| Professional | | $504.17 | $888.08 | $1,257.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.17 / $888.08 / $1,257.26
| Professional | | $504.17 | $888.08 | $1,257.26 |