- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.53 / $5,188.07 / $5,188.07
| Professional | | $708.53 | $5,188.07 | $5,188.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,028.38 / $1,955.64 / $1,955.64
| Facility | | $1,028.38 | $1,955.64 | $1,955.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.38 / $1,955.64 / $1,955.64
| Professional | | $1,028.38 | $1,955.64 | $1,955.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $917.56 / $1,862.51 / $1,955.64
| Facility | | $917.56 | $1,862.51 | $1,955.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.47 / $1,500.32 / $1,957.06
| Professional | | $1,448.47 | $1,500.32 | $1,957.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.09 / $821.06 / $1,256.45
| Professional | | $742.09 | $821.06 | $1,256.45 |