- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,028.55 / $1,067.11 / $2,815.66
| Facility | | $1,028.55 | $1,067.11 | $2,815.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.55 / $1,067.11 / $1,173.83
| Professional | | $1,028.55 | $1,067.11 | $1,173.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,092.83 / $1,092.83 / $1,092.83
| Facility | | $1,092.83 | $1,092.83 | $1,092.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.83 / $1,092.83 / $1,092.83
| Professional | | $1,092.83 | $1,092.83 | $1,092.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $452.68 / $470.79 / $1,092.83
| Facility | | $452.68 | $470.79 | $1,092.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.41 / $1,092.83 / $1,092.83
| Professional | | $546.41 | $1,092.83 | $1,092.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Professional | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.41 / $1,135.69 / $1,192.48
| Professional | | $1,071.41 | $1,135.69 | $1,192.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.82 / $1,071.41 / $1,071.41
| Professional | | $507.82 | $1,071.41 | $1,071.41 |