- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.57 / $707.57 / $707.57
| Facility | | $707.57 | $707.57 | $707.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.57 / $707.57 / $707.57
| Professional | | $707.57 | $707.57 | $707.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.00 / $1,800.00 / $1,800.00
| Professional | | $1,800.00 | $1,800.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.14 / $517.14 / $517.14
| Professional | | $517.14 | $517.14 | $517.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.30 / $700.30 / $2,138.66
| Professional | | $700.30 | $700.30 | $2,138.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.33 / $537.49 / $944.03
| Professional | | $358.33 | $537.49 | $944.03 |