- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $512.86 / $1,000.00
| Professional | | $407.38 | $512.86 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $50,118.72 / $50,118.72
| Facility | | $6,309.57 | $50,118.72 | $50,118.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Professional | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $331.13 / $562.34
| Facility | | $263.03 | $331.13 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $331.13 / $562.34
| Facility | | $263.03 | $331.13 | $562.34 |