- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,550.00 / $15,705.00 / $16,530.00
| Facility | | $8,550.00 | $15,705.00 | $16,530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.22 / $1,270.80 / $5,707.27
| Professional | | $318.22 | $1,270.80 | $5,707.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.30 / $1,912.00 / $2,151.00
| Professional | | $1,601.30 | $1,912.00 | $2,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.84 / $673.84 / $673.84
| Professional | | $673.84 | $673.84 | $673.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.22 / $1,270.80 / $1,963.12
| Facility | | $318.22 | $1,270.80 | $1,963.12 |