- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $684.09 / $684.09 / $1,756.44
| Facility | | $684.09 | $684.09 | $1,756.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $684.09 / $931.39 / $1,756.44
| Professional | | $684.09 | $931.39 | $1,756.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,111.46 / $2,111.46 / $2,111.46
| Facility | | $2,111.46 | $2,111.46 | $2,111.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.60 / $1,062.60 / $2,329.86
| Professional | | $1,062.60 | $1,062.60 | $2,329.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.24 / $1,375.24 / $1,554.42
| Facility | | $1,375.24 | $1,375.24 | $1,554.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.93 / $1,375.24 / $1,416.50
| Professional | | $1,003.93 | $1,375.24 | $1,416.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.17 / $1,689.18 / $2,744.91
| Professional | | $1,174.17 | $1,689.18 | $2,744.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.01 / $871.76 / $1,410.83
| Professional | | $806.01 | $871.76 | $1,410.83 |