- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.00 / $477.00 / $6,445.22
| Facility | | $477.00 | $477.00 | $6,445.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.00 / $477.00 / $1,895.65
| Professional | | $477.00 | $477.00 | $1,895.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,421.02 / $6,170.03 / $9,722.17
| Facility | | $3,421.02 | $6,170.03 | $9,722.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.91 / $657.70 / $730.05
| Professional | | $597.91 | $657.70 | $730.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,159.42 / $3,159.42 / $3,159.42
| Facility | | $3,159.42 | $3,159.42 | $3,159.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,306.14 / $6,061.32 / $22,313.37
| Facility | | $3,306.14 | $6,061.32 | $22,313.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,701.13 / $4,107.25
| Professional | | $1,326.96 | $1,701.13 | $4,107.25 |