- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.68 / $879.12 / $3,904.46
| Professional | | $496.68 | $879.12 | $3,904.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.75 / $1,253.47 / $1,793.29
| Facility | | $330.75 | $1,253.47 | $1,793.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.46 / $3,853.58 / $3,853.58
| Professional | | $1,869.46 | $3,853.58 | $3,853.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $998.00 / $998.00 / $998.00
| Facility | | $998.00 | $998.00 | $998.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.68 / $1,628.74 / $1,667.52
| Professional | | $961.68 | $1,628.74 | $1,667.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $5.00 / $2,447.80
| Professional | | $5.00 | $5.00 | $2,447.80 |