- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.78 / $622.20 / $5,000.00
| Facility | | $437.78 | $622.20 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.60 / $526.33 / $622.20
| Professional | | $404.60 | $526.33 | $622.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.85 / $1,130.92 / $1,504.51
| Professional | | $873.85 | $1,130.92 | $1,504.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.83 / $1,163.03 / $1,597.49
| Professional | | $618.83 | $1,163.03 | $1,597.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.78 / $622.20 / $1,040.83
| Facility | | $437.78 | $622.20 | $1,040.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.09 / $1,141.43 / $3,291.68
| Professional | | $634.09 | $1,141.43 | $3,291.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.09 / $1,108.48 / $1,342.89
| Professional | | $634.09 | $1,108.48 | $1,342.89 |