- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.74 / $1,370.74 / $1,462.79
| Professional | | $1,370.74 | $1,370.74 | $1,462.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.98 / $1,431.98 / $1,685.57
| Professional | | $1,431.98 | $1,431.98 | $1,685.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,082.51 / $1,082.51 / $2,233.78
| Facility | | $1,082.51 | $1,082.51 | $2,233.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $1,082.51 / $1,566.00
| Professional | | $161.82 | $1,082.51 | $1,566.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,867.10 / $1,867.10 / $1,867.10
| Professional | | $1,867.10 | $1,867.10 | $1,867.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.61 / $1,370.74 / $1,462.79
| Professional | | $962.61 | $1,370.74 | $1,462.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.67 / $972.51 / $1,899.92
| Professional | | $643.67 | $972.51 | $1,899.92 |