- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,090.30
| Professional | | $2,454.71 | $2,454.71 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,148.15 / $5,495.41
| Facility | | $776.25 | $1,148.15 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $1,023.29 / $2,344.23
| Professional | | $524.81 | $1,023.29 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,445.44 / $1,862.09
| Facility | | $1,047.13 | $1,445.44 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $812.83 / $1,202.26
| Professional | | $524.81 | $812.83 | $1,202.26 |