- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $711.10 / $711.10 / $2,300.00
| Facility | | $711.10 | $711.10 | $2,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.48 / $605.66 / $876.36
| Professional | | $352.48 | $605.66 | $876.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,883.20 / $13,139.60 / $26,250.84
| Facility | | $2,883.20 | $13,139.60 | $26,250.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119,998.80 / $119,998.80 / $119,998.80
| Professional | | $119,998.80 | $119,998.80 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $828.88 / $828.88 / $828.88
| Facility | | $828.88 | $828.88 | $828.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,140.04 / $3,140.04 / $3,140.04
| Professional | | $3,140.04 | $3,140.04 | $3,140.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.33 / $441.53 / $868.71
| Professional | | $276.33 | $441.53 | $868.71 |