- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,698.24 / $3,019.95
| Professional | | $912.01 | $1,698.24 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,949.84 / $3,019.95
| Professional | | $1,230.27 | $1,949.84 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,862.09 / $2,951.21
| Professional | | $1,621.81 | $1,862.09 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $2,570.40
| Professional | | $1,621.81 | $1,949.84 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,089.30 / $3,981.07
| Professional | | $1,513.56 | $2,089.30 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,949.84 / $2,570.40
| Professional | | $1,445.44 | $1,949.84 | $2,570.40 |