- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Professional | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $8,317.64 / $9,549.93
| Facility | | $1,445.44 | $8,317.64 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,754.23 / $3,548.13
| Professional | | $2,137.96 | $2,754.23 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,513.56 / $2,137.96
| Facility | | $954.99 | $1,513.56 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,754.23 / $3,090.30
| Professional | | $2,137.96 | $2,754.23 | $3,090.30 |