- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.78 / $1,297.65 / $1,613.55
| Professional | | $731.78 | $1,297.65 | $1,613.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,910.52 / $1,976.24 / $1,976.24
| Professional | | $1,910.52 | $1,976.24 | $1,976.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.60 / $1,436.52 / $1,436.52
| Facility | | $192.60 | $1,436.52 | $1,436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.43 / $1,436.52 / $3,759.38
| Professional | | $183.43 | $1,436.52 | $3,759.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $710.47 / $1,297.65 / $2,321.79
| Facility | | $710.47 | $1,297.65 | $2,321.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.47 / $710.47 / $710.47
| Professional | | $710.47 | $710.47 | $710.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,855.62 / $1,855.62 / $9,609.00
| Professional | | $1,855.62 | $1,855.62 | $9,609.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.02 / $1,092.43 / $1,657.76
| Professional | | $993.02 | $1,092.43 | $1,657.76 |