- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.87 / $4,282.54 / $4,282.54
| Professional | | $584.87 | $4,282.54 | $4,282.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $752.15 / $1,439.26 / $1,439.26
| Facility | | $752.15 | $1,439.26 | $1,439.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.15 / $1,439.26 / $1,439.26
| Professional | | $752.15 | $1,439.26 | $1,439.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $671.10 / $1,370.72 / $1,439.26
| Facility | | $671.10 | $1,370.72 | $1,439.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.23 / $1,104.16 / $1,477.69
| Professional | | $1,080.23 | $1,104.16 | $1,477.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.76 / $600.52 / $687.43
| Professional | | $542.76 | $600.52 | $687.43 |