- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $714.02 / $1,073.64 / $1,136.79
| Professional | | $714.02 | $1,073.64 | $1,136.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.70 / $975.70 / $975.70
| Professional | | $975.70 | $975.70 | $975.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.44 / $1,042.44 / $1,042.44
| Facility | | $1,042.44 | $1,042.44 | $1,042.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.94 / $1,042.44 / $2,090.63
| Professional | | $119.94 | $1,042.44 | $2,090.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.41 / $634.87 / $944.87
| Professional | | $428.41 | $634.87 | $944.87 |