- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $825.53 / $1,133.98 / $2,231.81
| Professional | | $825.53 | $1,133.98 | $2,231.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.78 / $1,208.78 / $1,208.78
| Facility | | $1,208.78 | $1,208.78 | $1,208.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.46 / $1,208.78 / $3,123.75
| Professional | | $1,027.46 | $1,208.78 | $3,123.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,179.80 / $5,179.80 / $5,179.80
| Professional | | $5,179.80 | $5,179.80 | $5,179.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,792.80 / $1,792.80 / $1,792.80
| Professional | | $1,792.80 | $1,792.80 | $1,792.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.01 / $1,283.94 / $1,722.36
| Professional | | $1,036.01 | $1,283.94 | $1,722.36 |