- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.32 / $3,424.75 / $3,424.75
| Professional | | $818.32 | $3,424.75 | $3,424.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.58 / $1,020.58 / $1,020.58
| Facility | | $1,020.58 | $1,020.58 | $1,020.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.97 / $1,020.58 / $1,083.09
| Professional | | $790.97 | $1,020.58 | $1,083.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $505.13 / $1,166.09 / $1,219.46
| Facility | | $505.13 | $1,166.09 | $1,219.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.29 / $923.04 / $1,331.40
| Professional | | $615.29 | $923.04 | $1,331.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.94 / $1,123.80 / $1,772.30
| Professional | | $914.94 | $1,123.80 | $1,772.30 |