- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.60 / $477.60 / $477.60
| Professional | | $477.60 | $477.60 | $477.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $88.83 / $827.00 / $1,688.67
| Facility | | $88.83 | $827.00 | $1,688.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.75 / $201.09 / $450.31
| Professional | | $154.75 | $201.09 | $450.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $682.97 / $852.66 / $3,103.38
| Facility | | $682.97 | $852.66 | $3,103.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.63 / $1,243.13 / $1,685.26
| Professional | | $784.63 | $1,243.13 | $1,685.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.56 / $409.37 / $1,197.34
| Professional | | $286.56 | $409.37 | $1,197.34 |