- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $548.48 / $960.00 / $2,250.00
| Facility | | $548.48 | $960.00 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.49 / $330.14 / $548.48
| Professional | | $251.49 | $330.14 | $548.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,292.50 / $1,568.51 / $2,110.16
| Facility | | $1,292.50 | $1,568.51 | $2,110.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.00 / $426.50 / $1,119.33
| Professional | | $248.00 | $426.50 | $1,119.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $625.00 / $1,738.00 / $3,360.00
| Facility | | $625.00 | $1,738.00 | $3,360.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.44 / $292.68 / $487.08
| Professional | | $209.44 | $292.68 | $487.08 |