- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $912.01 / $2,238.72
| Professional | | $707.95 | $912.01 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $933.25 / $1,148.15
| Professional | | $851.14 | $933.25 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,096.48 / $2,137.96
| Professional | | $758.58 | $1,096.48 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $870.96 / $1,445.44
| Professional | | $776.25 | $870.96 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,000.00 / $1,659.59
| Professional | | $724.44 | $1,000.00 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $977.24 / $1,148.15
| Professional | | $794.33 | $977.24 | $1,148.15 |