- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,230.27 / $2,344.23
| Facility | | $776.25 | $1,230.27 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,000.00 / $1,230.27
| Professional | | $776.25 | $1,000.00 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $2,951.21
| Professional | | $1,698.24 | $2,511.89 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,862.09
| Professional | | $1,513.56 | $1,513.56 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $2,344.23
| Facility | | $724.44 | $1,000.00 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,318.26 / $2,238.72
| Professional | | $467.74 | $1,318.26 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,318.26 / $1,905.46
| Professional | | $467.74 | $1,318.26 | $1,905.46 |