- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.14 / $1,245.30 / $6,571.36
| Professional | | $945.14 | $1,245.30 | $6,571.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,011.19 / $2,011.19 / $2,011.19
| Facility | | $2,011.19 | $2,011.19 | $2,011.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.55 / $1,886.26 / $3,308.60
| Professional | | $1,117.55 | $1,886.26 | $3,308.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,241.98 / $1,625.00 / $2,138.48
| Facility | | $1,241.98 | $1,625.00 | $2,138.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.00 / $2,057.59 / $3,428.68
| Professional | | $1,252.00 | $2,057.59 | $3,428.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.34 / $2,074.80 / $3,038.10
| Professional | | $1,741.34 | $2,074.80 | $3,038.10 |