- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $953.86 / $1,294.20 / $5,023.87
| Professional | | $953.86 | $1,294.20 | $5,023.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,526.92 / $1,526.92 / $1,526.92
| Facility | | $1,526.92 | $1,526.92 | $1,526.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.41 / $1,526.92 / $1,623.20
| Professional | | $727.41 | $1,526.92 | $1,623.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $756.57 / $1,010.18 / $1,526.92
| Facility | | $756.57 | $1,010.18 | $1,526.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.59 / $1,526.92 / $2,052.40
| Professional | | $923.59 | $1,526.92 | $2,052.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.60 / $1,612.40 / $1,935.11
| Professional | | $1,298.60 | $1,612.40 | $1,935.11 |