- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.00 / $306.00 / $5,787.00
| Professional | | $306.00 | $306.00 | $5,787.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,797.45 / $1,797.45 / $1,870.92
| Facility | | $1,797.45 | $1,797.45 | $1,870.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,506.38 / $1,506.38 / $1,981.33
| Facility | | $1,506.38 | $1,506.38 | $1,981.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,022.32 / $2,022.32 / $2,022.32
| Professional | | $2,022.32 | $2,022.32 | $2,022.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,506.38 / $1,506.38 / $1,981.33
| Facility | | $1,506.38 | $1,506.38 | $1,981.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.00 / $585.00 / $2,022.32
| Professional | | $585.00 | $585.00 | $2,022.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.12 / $1,260.00 / $2,079.36
| Professional | | $393.12 | $1,260.00 | $2,079.36 |