- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,056.00 / $10,327.73 / $15,576.74
| Facility | | $2,056.00 | $10,327.73 | $15,576.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,093.32 / $4,093.32 / $4,093.32
| Professional | | $4,093.32 | $4,093.32 | $4,093.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.38 / $251.23 / $338.68
| Facility | | $215.38 | $251.23 | $338.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $699.61 / $4,933.00 / $15,576.74
| Facility | | $699.61 | $4,933.00 | $15,576.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.61 / $699.61 / $1,264.17
| Professional | | $699.61 | $699.61 | $1,264.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $50.00
| Professional | | $30.00 | $30.00 | $50.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $464.00 / $1,428.00 / $2,029.00
| Facility | | $464.00 | $1,428.00 | $2,029.00 |