- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.49 / $3,922.65 / $3,922.65
| Professional | | $774.49 | $3,922.65 | $3,922.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,170.43 / $1,170.43 / $1,170.43
| Facility | | $1,170.43 | $1,170.43 | $1,170.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.09 / $1,170.43 / $1,243.15
| Professional | | $850.09 | $1,170.43 | $1,243.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $578.49 / $1,370.20 / $1,410.48
| Facility | | $578.49 | $1,370.20 | $1,410.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.26 / $1,056.50 / $1,523.90
| Professional | | $704.26 | $1,056.50 | $1,523.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.08 / $1,267.92 / $2,032.22
| Professional | | $1,075.08 | $1,267.92 | $2,032.22 |