- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.78 / $1,201.78 / $7,968.00
| Facility | | $1,201.78 | $1,201.78 | $7,968.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.78 / $1,201.78 / $1,201.78
| Professional | | $1,201.78 | $1,201.78 | $1,201.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.78 / $1,201.78 / $1,742.58
| Facility | | $1,201.78 | $1,201.78 | $1,742.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $361.00 / $832.00 / $1,928.00
| Facility | | $361.00 | $832.00 | $1,928.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |