- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.00 / $477.00 / $5,686.96
| Facility | | $477.00 | $477.00 | $5,686.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.00 / $477.00 / $2,969.85
| Professional | | $477.00 | $477.00 | $2,969.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,755.72 / $6,366.23 / $7,108.70
| Professional | | $4,755.72 | $6,366.23 | $7,108.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.27 / $3,630.27 / $5,329.40
| Professional | | $3,630.27 | $3,630.27 | $5,329.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.00 / $1,769.28 / $4,739.13
| Facility | | $477.00 | $1,769.28 | $4,739.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.30 / $3,791.30 / $6,318.84
| Professional | | $1,611.30 | $3,791.30 | $6,318.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $3,222.61 / $6,318.84
| Professional | | $1,326.96 | $3,222.61 | $6,318.84 |