- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.00 / $2,008.24 / $2,008.24
| Professional | | $1,453.00 | $2,008.24 | $2,008.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.32 / $1,366.32 / $1,366.32
| Facility | | $1,366.32 | $1,366.32 | $1,366.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.41 / $997.41 / $1,407.31
| Professional | | $997.41 | $997.41 | $1,407.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $739.46 / $1,795.38 / $2,389.03
| Facility | | $739.46 | $1,795.38 | $2,389.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,150.13 / $2,269.58 / $2,389.03
| Professional | | $2,150.13 | $2,269.58 | $2,389.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $1,763.10 / $2,099.73
| Professional | | $30.00 | $1,763.10 | $2,099.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,091.92 / $2,333.04 / $3,499.56
| Facility | | $2,091.92 | $2,333.04 | $3,499.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,672.32 / $1,732.21 / $2,508.48
| Professional | | $1,672.32 | $1,732.21 | $2,508.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,008.60 / $1,090.86 / $1,795.38
| Professional | | $1,008.60 | $1,090.86 | $1,795.38 |