- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $287.56 / $9,859.00
| Facility | | $100.00 | $287.56 | $9,859.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.56 / $287.56 / $287.56
| Professional | | $287.56 | $287.56 | $287.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,421.47 / $2,143.78 / $3,584.04
| Professional | | $1,421.47 | $2,143.78 | $3,584.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,035.00 / $8,035.00 / $8,035.00
| Facility | | $8,035.00 | $8,035.00 | $8,035.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,501.48 / $2,092.42 / $3,584.04
| Professional | | $1,501.48 | $2,092.42 | $3,584.04 |