- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,213.80 / $1,713.00 / $4,473.00
| Facility | | $1,213.80 | $1,713.00 | $4,473.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.97 / $1,213.80 / $2,228.67
| Professional | | $224.97 | $1,213.80 | $2,228.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $511.13 / $7,759.00 / $14,510.00
| Facility | | $511.13 | $7,759.00 | $14,510.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $458.50 / $508.93 / $1,762.69
| Professional | | $458.50 | $508.93 | $1,762.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $493.00
| Professional | | $200.00 | $200.00 | $493.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,061.00 / $2,606.00 / $6,471.00
| Facility | | $1,061.00 | $2,606.00 | $6,471.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.56 / $1,467.53 / $2,168.94
| Professional | | $1,082.56 | $1,467.53 | $2,168.94 |