- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,660.08 / $1,660.08 / $2,838.62
| Facility | | $1,660.08 | $1,660.08 | $2,838.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.08 / $1,660.08 / $2,075.10
| Professional | | $1,047.08 | $1,660.08 | $2,075.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,950.00 / $1,950.00 / $2,601.66
| Facility | | $1,950.00 | $1,950.00 | $2,601.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.82 / $1,950.00 / $3,611.25
| Professional | | $244.82 | $1,950.00 | $3,611.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.50 / $2,119.19 / $17,045.09
| Facility | | $311.50 | $2,119.19 | $17,045.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.55 / $1,490.62 / $2,412.83
| Professional | | $835.55 | $1,490.62 | $2,412.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.62 / $1,336.88 / $2,412.83
| Professional | | $982.62 | $1,336.88 | $2,412.83 |