- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.57 / $765.81 / $946.89
| Professional | | $697.57 | $765.81 | $946.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,257.27 / $3,048.71 / $3,609.32
| Facility | | $2,257.27 | $3,048.71 | $3,609.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.36 / $1,042.78 / $1,443.75
| Professional | | $886.36 | $1,042.78 | $1,443.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $923.47 / $1,057.34 / $1,057.34
| Facility | | $923.47 | $1,057.34 | $1,057.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.87 / $1,057.34 / $1,057.34
| Professional | | $771.87 | $1,057.34 | $1,057.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.59 / $796.49 / $1,327.48
| Professional | | $577.59 | $796.49 | $1,327.48 |