- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $717.67 / $717.67 / $717.67
| Facility | | $717.67 | $717.67 | $717.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.70 / $717.67 / $1,174.83
| Professional | | $68.70 | $717.67 | $1,174.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,404.74 / $3,404.74 / $3,404.74
| Facility | | $3,404.74 | $3,404.74 | $3,404.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.34 / $83.47 / $90.15
| Professional | | $75.34 | $83.47 | $90.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.00 / $120.00 / $120.00
| Facility | | $120.00 | $120.00 | $120.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.00 / $102.00 / $1,752.44
| Professional | | $102.00 | $102.00 | $1,752.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $717.67 / $1,078.31 / $2,086.23
| Facility | | $717.67 | $1,078.31 | $2,086.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.31 / $1,078.31 / $1,078.31
| Professional | | $1,078.31 | $1,078.31 | $1,078.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.29 / $1,919.34 / $3,304.60
| Professional | | $1,168.29 | $1,919.34 | $3,304.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.50 / $69.12 / $114.17
| Professional | | $68.50 | $69.12 | $114.17 |