- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $754.28 / $938.05 / $1,638.98
| Professional | | $754.28 | $938.05 | $1,638.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,826.63 / $1,826.63 / $1,826.63
| Facility | | $1,826.63 | $1,826.63 | $1,826.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.42 / $1,287.45 / $2,815.98
| Professional | | $964.42 | $1,287.45 | $2,815.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,094.41 / $1,323.51 / $2,300.21
| Facility | | $1,094.41 | $1,323.51 | $2,300.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.29 / $2,127.96 / $3,120.49
| Professional | | $1,217.29 | $2,127.96 | $3,120.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,303.39 / $1,569.39 / $1,862.00
| Professional | | $1,303.39 | $1,569.39 | $1,862.00 |