- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,061.22 / $1,061.22 / $1,061.22
| Facility | | $1,061.22 | $1,061.22 | $1,061.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.37 / $1,061.22 / $1,651.77
| Professional | | $829.37 | $1,061.22 | $1,651.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,467.67 / $4,174.88 / $17,765.20
| Facility | | $2,467.67 | $4,174.88 | $17,765.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,335.63 / $1,335.63 / $2,260.02
| Facility | | $1,335.63 | $1,335.63 | $2,260.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.01 / $1,335.63 / $2,393.63
| Professional | | $975.01 | $1,335.63 | $2,393.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.46 / $2,308.66 / $2,841.74
| Professional | | $1,775.46 | $2,308.66 | $2,841.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,684.12 / $2,684.12 / $2,684.12
| Professional | | $2,684.12 | $2,684.12 | $2,684.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.36 / $1,030.06 / $1,808.65
| Professional | | $762.36 | $1,030.06 | $1,808.65 |