- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $2,754.23
| Professional | | $1,412.54 | $1,905.46 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $2,398.83 / $3,981.07
| Professional | | $251.19 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,290.87 / $2,290.87
| Professional | | $2,089.30 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $316.23 / $2,137.96
| Facility | | $147.91 | $316.23 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,412.54 / $2,511.89
| Professional | | $1,000.00 | $1,412.54 | $2,511.89 |