- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,918.65 / $2,232.66 / $2,754.19
| Professional | | $1,918.65 | $2,232.66 | $2,754.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $491.13 / $491.13 / $491.13
| Facility | | $491.13 | $491.13 | $491.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.00 / $320.00 / $320.00
| Professional | | $320.00 | $320.00 | $320.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,032.02 / $2,387.48 / $2,387.48
| Facility | | $2,032.02 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.77 / $2,361.94 / $2,387.48
| Professional | | $251.77 | $2,361.94 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.81 / $1,333.17 / $2,541.66
| Professional | | $761.81 | $1,333.17 | $2,541.66 |