- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,778.28 / $3,090.30
| Professional | | $977.24 | $1,778.28 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,041.74 / $3,090.30
| Professional | | $1,258.93 | $2,041.74 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,949.84 / $3,090.30
| Professional | | $1,548.82 | $1,949.84 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $2,691.53
| Professional | | $1,698.24 | $2,041.74 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $3,981.07
| Professional | | $1,479.11 | $2,187.76 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,041.74 / $2,691.53
| Professional | | $1,445.44 | $2,041.74 | $2,691.53 |