- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,051.10 / $10,747.80 / $14,091.10
| Facility | | $2,051.10 | $10,747.80 | $14,091.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,051.10 / $2,051.10 / $2,051.10
| Professional | | $2,051.10 | $2,051.10 | $2,051.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,947.98 / $2,003.49 / $6,279.44
| Facility | | $1,947.98 | $2,003.49 | $6,279.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.80 / $2,734.80 / $2,734.80
| Professional | | $2,734.80 | $2,734.80 | $2,734.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,279.00 / $2,620.85 / $2,734.80
| Facility | | $2,279.00 | $2,620.85 | $2,734.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,072.66 / $2,359.82 / $3,160.75
| Professional | | $2,072.66 | $2,359.82 | $3,160.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.18 / $957.18 / $1,367.40
| Professional | | $957.18 | $957.18 | $1,367.40 |