- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $591.41 / $591.41 / $591.41
| Professional | | $591.41 | $591.41 | $591.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $3,349.85
| Facility | | $3,349.85 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.67 / $3,349.85 / $5,049.00
| Professional | | $356.67 | $3,349.85 | $5,049.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,420.32 / $3,025.40 / $6,092.48
| Facility | | $2,420.32 | $3,025.40 | $6,092.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.67 / $3,349.85 / $5,049.00
| Professional | | $356.67 | $3,349.85 | $5,049.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.32 / $1,741.32 / $2,902.20
| Professional | | $1,741.32 | $1,741.32 | $2,902.20 |