- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.46 / $1,067.36 / $1,912.43
| Professional | | $707.46 | $1,067.36 | $1,912.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.39 / $1,071.00 / $1,071.00
| Facility | | $171.39 | $1,071.00 | $1,071.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.39 / $1,071.00 / $2,677.50
| Professional | | $171.39 | $1,071.00 | $2,677.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,273.73 / $5,273.73 / $5,273.73
| Professional | | $5,273.73 | $5,273.73 | $5,273.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,536.32 / $1,562.13 / $1,562.13
| Professional | | $1,536.32 | $1,562.13 | $1,562.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.86 / $1,134.04 / $2,126.71
| Professional | | $887.86 | $1,134.04 | $2,126.71 |