- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.65 / $1,126.83 / $1,206.32
| Professional | | $850.65 | $1,126.83 | $1,206.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,752.61 / $3,717.74 / $4,401.37
| Facility | | $2,752.61 | $3,717.74 | $4,401.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.67 / $1,023.14 / $1,711.12
| Professional | | $869.67 | $1,023.14 | $1,711.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,125.11 / $1,576.65 / $1,576.65
| Facility | | $1,125.11 | $1,576.65 | $1,576.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.95 / $1,576.65 / $1,576.65
| Professional | | $1,150.95 | $1,576.65 | $1,576.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.26 / $1,111.83 / $1,618.79
| Professional | | $914.26 | $1,111.83 | $1,618.79 |