- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.21 / $1,205.41 / $5,954.09
| Professional | | $923.21 | $1,205.41 | $5,954.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,950.19 / $1,950.19 / $1,950.19
| Facility | | $1,950.19 | $1,950.19 | $1,950.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.10 / $1,109.10 / $1,950.19
| Professional | | $1,109.10 | $1,109.10 | $1,950.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,141.47 / $1,536.35 / $2,098.64
| Facility | | $1,141.47 | $1,536.35 | $2,098.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,197.27 / $1,995.58 / $3,325.35
| Professional | | $1,197.27 | $1,995.58 | $3,325.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.01 / $1,937.40 / $2,363.44
| Professional | | $1,556.01 | $1,937.40 | $2,363.44 |