- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,430.04 / $7,757.09 / $7,757.09
| Facility | | $1,430.04 | $7,757.09 | $7,757.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.54 / $1,028.54 / $1,028.54
| Professional | | $1,028.54 | $1,028.54 | $1,028.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $335.33 / $335.33 / $335.33
| Facility | | $335.33 | $335.33 | $335.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.02 / $335.33 / $335.33
| Professional | | $285.02 | $335.33 | $335.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,092.73 / $22,889.34 / $47,249.53
| Facility | | $2,092.73 | $22,889.34 | $47,249.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.54 / $2,441.53 / $48,173.27
| Professional | | $2,005.54 | $2,441.53 | $48,173.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,133.57 / $1,356.97 / $2,301.15
| Facility | | $1,133.57 | $1,356.97 | $2,301.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,023.91 / $8,405.84 / $8,405.84
| Professional | | $2,023.91 | $8,405.84 | $8,405.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.09 / $670.79 / $1,117.98
| Professional | | $503.09 | $670.79 | $1,117.98 |