- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,342.89 / $1,558.00 / $7,644.25
| Professional | | $1,342.89 | $1,558.00 | $7,644.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,313.52 / $2,313.52 / $2,313.52
| Facility | | $2,313.52 | $2,313.52 | $2,313.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.99 / $2,313.52 / $2,476.98
| Professional | | $1,229.99 | $2,313.52 | $2,476.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,144.82 / $1,574.13 / $2,313.52
| Facility | | $1,144.82 | $1,574.13 | $2,313.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.08 / $2,313.52 / $3,031.70
| Professional | | $1,401.08 | $2,313.52 | $3,031.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,977.78 / $2,416.80 / $2,713.60
| Professional | | $1,977.78 | $2,416.80 | $2,713.60 |