- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.79 / $900.62 / $1,344.11
| Professional | | $354.79 | $900.62 | $1,344.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $390.06 / $1,404.74 / $2,436.54
| Facility | | $390.06 | $1,404.74 | $2,436.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.29 / $682.29 / $3,288.64
| Professional | | $682.29 | $682.29 | $3,288.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,187.18 / $3,240.88 / $3,240.88
| Facility | | $1,187.18 | $3,240.88 | $3,240.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,411.45 / $3,411.45 / $5,117.18
| Professional | | $3,411.45 | $3,411.45 | $5,117.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.56 / $409.37 / $691.18
| Professional | | $286.56 | $409.37 | $691.18 |