- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,080.86 / $6,080.86 / $6,080.86
| Facility | | $6,080.86 | $6,080.86 | $6,080.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.57 / $4,463.60 / $6,080.86
| Professional | | $1,860.57 | $4,463.60 | $6,080.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,353.00 / $5,353.00 / $5,353.00
| Professional | | $5,353.00 | $5,353.00 | $5,353.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.00 / $2,900.00 / $2,900.00
| Facility | | $2,900.00 | $2,900.00 | $2,900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.34 / $2,900.00 / $9,848.44
| Professional | | $480.34 | $2,900.00 | $9,848.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,860.57 / $4,760.96 / $30,495.32
| Facility | | $1,860.57 | $4,760.96 | $30,495.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.98 / $2,860.46 / $4,767.43
| Professional | | $1,906.98 | $2,860.46 | $4,767.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.57 / $2,743.18 / $4,571.13
| Professional | | $1,860.57 | $2,743.18 | $4,571.13 |