- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,675.00 / $6,725.25 / $9,079.09
| Facility | | $3,675.00 | $6,725.25 | $9,079.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,903.25 / $2,903.25 / $2,903.25
| Professional | | $2,903.25 | $2,903.25 | $2,903.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,777.50 / $4,961.25 / $4,961.25
| Facility | | $4,777.50 | $4,961.25 | $4,961.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,388.75 / $2,388.75 / $2,508.19
| Facility | | $2,388.75 | $2,388.75 | $2,508.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.25 / $25.00 / $50.00
| Professional | | $21.25 | $25.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,543.50 / $2,205.00 / $6,273.11
| Professional | | $1,543.50 | $2,205.00 | $6,273.11 |