- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $2,041.74
| Professional | | $1,513.56 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $2,454.71
| Professional | | $288.40 | $288.40 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $501.19 / $676.08
| Professional | | $501.19 | $501.19 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $1,513.56 / $2,691.53
| Facility | | $199.53 | $1,513.56 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,818.38 / $4,897.79
| Professional | | $1,513.56 | $2,818.38 | $4,897.79 |