- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $401.94 / $401.94 / $2,710.00
| Facility | | $401.94 | $401.94 | $2,710.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.64 / $401.94 / $805.50
| Professional | | $381.64 | $401.94 | $805.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.00 / $1,572.05 / $2,520.88
| Professional | | $1,367.00 | $1,572.05 | $2,520.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,010.50 / $13,010.50 / $16,052.30
| Facility | | $13,010.50 | $13,010.50 | $16,052.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $50.00 / $60.00
| Professional | | $40.00 | $50.00 | $60.00 |