- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $346.74 / $616.60
| Professional | | $316.23 | $346.74 | $616.60 |
- 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
- $812.83 / $1,230.27 / $1,230.27
| Professional | | $812.83 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $616.60 / $977.24
| Professional | | $389.05 | $616.60 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,754.23 / $5,370.32
| Facility | | $1,288.25 | $2,754.23 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $616.60 / $1,288.25
| Professional | | $363.08 | $616.60 | $1,288.25 |