- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.72 / $1,464.14 / $1,491.43
| Professional | | $1,098.72 | $1,464.14 | $1,491.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,555.38 / $4,802.00 / $5,685.01
| Facility | | $3,555.38 | $4,802.00 | $5,685.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.09 / $1,642.46 / $2,274.04
| Professional | | $1,396.09 | $1,642.46 | $2,274.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,454.52 / $1,523.27 / $1,523.27
| Facility | | $1,454.52 | $1,523.27 | $1,523.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.99 / $1,523.27 / $1,523.27
| Professional | | $1,111.99 | $1,523.27 | $1,523.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.86 / $1,436.10 / $2,090.90
| Professional | | $1,133.86 | $1,436.10 | $2,090.90 |