- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,000.00 / $2,187.76
| Professional | | $933.25 | $1,000.00 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $6,165.95 / $8,128.31
| Facility | | $5,754.40 | $6,165.95 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,548.82 / $1,995.26
| Professional | | $933.25 | $1,548.82 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $2,137.96
| Professional | | $1,000.00 | $1,258.93 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,479.11 / $2,089.30
| Professional | | $1,230.27 | $1,479.11 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $2,691.53
| Professional | | $977.24 | $1,288.25 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,288.25 / $2,137.96
| Professional | | $933.25 | $1,288.25 | $2,137.96 |