- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.35 / $1,401.37 / $1,751.71
| Professional | | $875.35 | $1,401.37 | $1,751.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,204.08 / $2,217.64 / $2,217.64
| Facility | | $2,204.08 | $2,217.64 | $2,217.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,884.99 / $2,217.64 / $3,059.25
| Professional | | $1,884.99 | $2,217.64 | $3,059.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,613.67 / $1,839.30 / $12,404.85
| Facility | | $1,613.67 | $1,839.30 | $12,404.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.71 / $1,341.43 / $2,017.09
| Professional | | $882.71 | $1,341.43 | $2,017.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.39 / $1,324.07 / $2,017.09
| Professional | | $1,103.39 | $1,324.07 | $2,017.09 |