- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.73 / $3,486.35 / $3,486.35
| Professional | | $689.73 | $3,486.35 | $3,486.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.13 / $1,052.13 / $1,052.13
| Facility | | $1,052.13 | $1,052.13 | $1,052.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.81 / $1,052.13 / $1,092.41
| Professional | | $736.81 | $1,052.13 | $1,092.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.97 / $1,217.45 / $1,256.78
| Facility | | $520.97 | $1,217.45 | $1,256.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.88 / $943.42 / $1,360.80
| Professional | | $628.88 | $943.42 | $1,360.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.23 / $1,119.82 / $1,820.40
| Professional | | $955.23 | $1,119.82 | $1,820.40 |