- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,910.00 / $1,910.00 / $1,910.00
| Facility | | $1,910.00 | $1,910.00 | $1,910.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,468.75 / $1,666.04 / $2,640.10
| Professional | | $1,468.75 | $1,666.04 | $2,640.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.33 / $303.33 / $303.33
| Facility | | $303.33 | $303.33 | $303.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.83 / $257.83 / $3,609.38
| Professional | | $257.83 | $257.83 | $3,609.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,881.84 / $1,881.84 / $1,881.84
| Professional | | $1,881.84 | $1,881.84 | $1,881.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.13 / $231.29 / $1,748.85
| Professional | | $141.13 | $231.29 | $1,748.85 |