- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,055.44 / $2,401.96 / $3,684.67
| Facility | | $2,055.44 | $2,401.96 | $3,684.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.38 / $906.70 / $1,069.22
| Professional | | $855.38 | $906.70 | $1,069.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $90.00 / $90.00
| Facility | | $90.00 | $90.00 | $90.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,849.18 / $2,849.18 / $2,849.18
| Professional | | $2,849.18 | $2,849.18 | $2,849.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.40 / $58.40 / $58.40
| Professional | | $58.40 | $58.40 | $58.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $90.00
| Facility | | $60.00 | $60.00 | $90.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,849.18 / $2,849.18 / $2,849.18
| Professional | | $2,849.18 | $2,849.18 | $2,849.18 |