- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.89 / $779.25 / $1,051.52
| Professional | | $651.89 | $779.25 | $1,051.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,066.91 / $3,066.91 / $3,809.25
| Facility | | $3,066.91 | $3,066.91 | $3,809.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.02 / $1,059.97 / $3,248.16
| Professional | | $873.02 | $1,059.97 | $3,248.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.02 / $959.71 / $2,183.98
| Professional | | $676.02 | $959.71 | $2,183.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.63 / $1,112.85 / $2,183.98
| Professional | | $804.63 | $1,112.85 | $2,183.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.63 / $1,072.83 / $3,118.81
| Professional | | $804.63 | $1,072.83 | $3,118.81 |