- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,695.39 / $2,695.39 / $2,695.39
| Professional | | $2,695.39 | $2,695.39 | $2,695.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.98 / $2,249.50 / $2,474.44
| Professional | | $1,751.98 | $2,249.50 | $2,474.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,095.19 / $2,095.19 / $2,095.19
| Facility | | $2,095.19 | $2,095.19 | $2,095.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $1,472.88 / $2,147.58
| Professional | | $192.51 | $1,472.88 | $2,147.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,695.39 / $2,695.39 / $2,730.62
| Professional | | $2,695.39 | $2,695.39 | $2,730.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.82 / $543.50 / $2,758.67
| Professional | | $109.82 | $543.50 | $2,758.67 |