- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.40 / $1,979.05 / $2,038.12
| Professional | | $1,640.40 | $1,979.05 | $2,038.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,650.48 / $2,067.66 / $2,245.57
| Professional | | $1,650.48 | $2,067.66 | $2,245.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Facility | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.17 / $2,225.09 / $3,768.75
| Professional | | $246.17 | $2,225.09 | $3,768.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.63 / $308.63 / $308.63
| Professional | | $308.63 | $308.63 | $308.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.47 / $1,106.56 / $1,782.64
| Professional | | $231.47 | $1,106.56 | $1,782.64 |