- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.83 / $1,254.83 / $1,303.34
| Professional | | $1,083.83 | $1,254.83 | $1,303.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.39 / $158.77 / $1,571.25
| Facility | | $116.39 | $158.77 | $1,571.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.34 / $138.91 / $1,692.12
| Professional | | $125.34 | $138.91 | $1,692.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.70 / $396.70 / $1,990.86
| Facility | | $396.70 | $396.70 | $1,990.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.88 / $396.70 / $8,325.59
| Professional | | $148.88 | $396.70 | $8,325.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.57 / $867.18 / $1,434.64
| Professional | | $649.57 | $867.18 | $1,434.64 |