- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $960.00 / $1,728.00 / $2,893.07
| Facility | | $960.00 | $1,728.00 | $2,893.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.25 / $2,893.07 / $2,893.07
| Professional | | $1,425.25 | $2,893.07 | $2,893.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,359.26 / $1,862.00 / $2,197.16
| Professional | | $1,359.26 | $1,862.00 | $2,197.16 |
- 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
- $1,183.38 / $1,498.95 / $2,364.60
| Professional | | $1,183.38 | $1,498.95 | $2,364.60 |