- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.83 / $1,157.78 / $5,544.93
| Professional | | $1,109.83 | $1,157.78 | $5,544.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,679.41 / $1,679.41 / $1,679.41
| Facility | | $1,679.41 | $1,679.41 | $1,679.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.49 / $1,679.41 / $1,737.85
| Professional | | $1,184.49 | $1,679.41 | $1,737.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $822.46 / $1,857.05 / $1,956.32
| Facility | | $822.46 | $1,857.05 | $1,956.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.61 / $1,532.58 / $2,210.60
| Professional | | $1,021.61 | $1,532.58 | $2,210.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.07 / $1,812.48 / $2,943.34
| Professional | | $1,457.07 | $1,812.48 | $2,943.34 |