- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,584.89
| Facility | | $1,202.26 | $1,202.26 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,230.27 / $1,258.93
| Professional | | $1,202.26 | $1,230.27 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $3,715.35 / $13,182.57
| Facility | | $977.24 | $3,715.35 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,258.93
| Professional | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $2,187.76 / $2,754.23
| Professional | | $181.97 | $2,187.76 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,398.83 / $2,398.83
| Facility | | $1,258.93 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,288.25
| Professional | | $1,258.93 | $1,258.93 | $1,288.25 |