- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.52 / $3,338.45 / $3,338.45
| Professional | | $962.52 | $3,338.45 | $3,338.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $930.44 / $1,214.93 / $1,214.93
| Facility | | $930.44 | $1,214.93 | $1,214.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.44 / $991.89 / $1,214.93
| Professional | | $930.44 | $991.89 | $1,214.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.10 / $1,157.08 / $1,214.93
| Facility | | $645.10 | $1,157.08 | $1,214.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.86 / $930.44 / $1,215.82
| Professional | | $911.86 | $930.44 | $1,215.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.74 / $577.25 / $915.52
| Professional | | $521.74 | $577.25 | $915.52 |