- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,000.00 / $1,778.28
| Facility | | $794.33 | $1,000.00 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $794.33 / $794.33
| Professional | | $380.19 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,818.38 / $4,466.84
| Facility | | $1,819.70 | $2,818.38 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $288.40
| Professional | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $794.33 / $977.24
| Facility | | $691.83 | $794.33 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $758.58 / $1,288.25
| Facility | | $218.78 | $758.58 | $1,288.25 |