- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.52 / $308.52 / $8,500.00
| Facility | | $308.52 | $308.52 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.52 / $308.52 / $318.79
| Professional | | $308.52 | $308.52 | $318.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.26 / $653.86 / $783.83
| Professional | | $600.26 | $653.86 | $783.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.98 / $722.93 / $933.56
| Professional | | $385.98 | $722.93 | $933.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.52 / $433.94 / $925.59
| Facility | | $308.52 | $433.94 | $925.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.27 / $585.63 / $798.41
| Professional | | $322.27 | $585.63 | $798.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.27 / $623.76 / $798.41
| Professional | | $322.27 | $623.76 | $798.41 |