- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.19 / $1,055.32 / $1,114.88
| Professional | | $899.19 | $1,055.32 | $1,114.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.00 / $1,103.20 / $1,213.52
| Professional | | $1,080.00 | $1,103.20 | $1,213.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.00 / $518.54 / $3,314.62
| Facility | | $507.00 | $518.54 | $3,314.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.68 / $1,356.21 / $2,319.71
| Professional | | $966.68 | $1,356.21 | $2,319.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.25 / $1,384.82 / $1,859.49
| Professional | | $1,070.25 | $1,384.82 | $1,859.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $643.00 / $643.00 / $1,185.00
| Facility | | $643.00 | $643.00 | $1,185.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.95 / $1,157.52 / $2,182.60
| Professional | | $829.95 | $1,157.52 | $2,182.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.66 / $1,234.52 / $1,515.66
| Professional | | $1,028.66 | $1,234.52 | $1,515.66 |