- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $973.77 / $973.77 / $973.77
| Facility | | $973.77 | $973.77 | $973.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.77 / $973.77 / $3,822.00
| Professional | | $973.77 | $973.77 | $3,822.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.13 / $141.13 / $141.13
| Professional | | $141.13 | $141.13 | $141.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,638.85 / $2,668.13 / $10,472.28
| Facility | | $1,638.85 | $2,668.13 | $10,472.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.13 / $141.13 / $141.13
| Facility | | $141.13 | $141.13 | $141.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.16 / $141.13 / $144.12
| Professional | | $128.16 | $141.13 | $144.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.51 / $373.51 / $373.51
| Professional | | $373.51 | $373.51 | $373.51 |