- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $732.50 / $971.22 / $3,582.16
| Professional | | $732.50 | $971.22 | $3,582.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,105.23 / $1,105.23 / $1,105.23
| Facility | | $1,105.23 | $1,105.23 | $1,105.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.12 / $1,105.23 / $1,130.83
| Professional | | $561.12 | $1,105.23 | $1,130.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $548.38 / $754.03 / $1,105.23
| Facility | | $548.38 | $754.03 | $1,105.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.50 / $1,105.23 / $1,435.70
| Professional | | $663.50 | $1,105.23 | $1,435.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.14 / $1,101.43 / $1,255.68
| Professional | | $922.14 | $1,101.43 | $1,255.68 |