- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,373.77 / $1,373.77 / $1,373.77
| Professional | | $1,373.77 | $1,373.77 | $1,373.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $648.23 / $786.65 / $1,058.30
| Facility | | $648.23 | $786.65 | $1,058.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.32 / $847.60 / $1,000.17
| Professional | | $593.32 | $847.60 | $1,000.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $699.96 / $1,727.00 / $2,719.93
| Facility | | $699.96 | $1,727.00 | $2,719.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $609.10 / $609.10 / $609.10
| Facility | | $609.10 | $609.10 | $609.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.58 / $816.96 / $982.34
| Professional | | $92.58 | $816.96 | $982.34 |