- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,080.00 / $5,795.78 / $7,420.19
| Facility | | $1,080.00 | $5,795.78 | $7,420.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,080.00 / $1,080.00
| Professional | | $1,000.00 | $1,080.00 | $1,080.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,918.00 / $5,512.00 / $8,381.00
| Facility | | $3,918.00 | $5,512.00 | $8,381.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.45 / $3,455.12 / $4,917.14
| Professional | | $726.45 | $3,455.12 | $4,917.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.51 / $83.51 / $83.51
| Professional | | $83.51 | $83.51 | $83.51 |