- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,388.44
| Professional | | $2,691.53 | $2,691.53 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $3,630.78
| Professional | | $151.36 | $151.36 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,398.83 / $2,951.21
| Facility | | $2,137.96 | $2,398.83 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,691.53 / $15,848.93
| Professional | | $2,398.83 | $2,691.53 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |