- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $2,398.83
| Professional | | $1,318.26 | $1,737.80 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $1,862.09 / $1,862.09
| Professional | | $251.19 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,754.23 / $9,332.54
| Professional | | $1,513.56 | $2,754.23 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $1,148.15 / $1,862.09
| Facility | | $151.36 | $1,148.15 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,548.82 / $2,754.23
| Professional | | $1,047.13 | $1,548.82 | $2,754.23 |