- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $2,691.53
| Professional | | $457.09 | $457.09 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $4,570.88
| Facility | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,754.23 / $6,309.57
| Professional | | $1,202.26 | $2,754.23 | $6,309.57 |