- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.11 / $357.24 / $1,467.00
| Professional | | $164.11 | $357.24 | $1,467.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,508.07 / $3,508.07 / $3,789.94
| Facility | | $3,508.07 | $3,508.07 | $3,789.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.17 / $381.09 / $1,423.60
| Professional | | $213.17 | $381.09 | $1,423.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.52 / $428.55 / $1,423.60
| Professional | | $233.52 | $428.55 | $1,423.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.61 / $513.37 / $1,747.31
| Professional | | $461.61 | $513.37 | $1,747.31 |