- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,823.09 / $3,127.02 / $3,908.78
| Professional | | $1,823.09 | $3,127.02 | $3,908.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.97 / $3,655.97 / $3,655.97
| Facility | | $3,655.97 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.57 / $3,655.97 / $5,865.00
| Professional | | $408.57 | $3,655.97 | $5,865.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $357.11 / $1,629.99 / $26,705.78
| Facility | | $357.11 | $1,629.99 | $26,705.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.57 / $2,471.30 / $3,802.00
| Professional | | $1,565.57 | $2,471.30 | $3,802.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,565.57 / $1,896.92 / $2,970.41
| Professional | | $1,565.57 | $1,896.92 | $2,970.41 |