- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.06 / $748.79 / $3,534.00
| Professional | | $80.06 | $748.79 | $3,534.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,182.61 / $3,182.61 / $4,076.01
| Facility | | $3,182.61 | $3,182.61 | $4,076.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.44 / $515.85 / $2,236.82
| Professional | | $128.44 | $515.85 | $2,236.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.85 / $994.11 / $2,236.82
| Professional | | $151.85 | $994.11 | $2,236.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.48 / $1,172.67 / $2,745.45
| Professional | | $1,000.48 | $1,172.67 | $2,745.45 |