- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,504.48 / $2,250.00
| Facility | | $960.00 | $1,504.48 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $827.88 / $1,504.48 / $1,504.48
| Professional | | $827.88 | $1,504.48 | $1,504.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.63 / $1,231.00 / $1,452.58
| Professional | | $898.63 | $1,231.00 | $1,452.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.70 / $1,209.47 / $3,117.57
| Professional | | $879.70 | $1,209.47 | $3,117.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $650.00 / $1,754.00 / $5,201.00
| Facility | | $650.00 | $1,754.00 | $5,201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.95 / $950.60 / $1,492.44
| Professional | | $712.95 | $950.60 | $1,492.44 |