- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.14 / $2,271.36 / $3,165.39
| Professional | | $1,830.14 | $2,271.36 | $3,165.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.78 / $250.78 / $250.78
| Professional | | $250.78 | $250.78 | $250.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,592.00 / $2,592.00 / $2,592.00
| Facility | | $2,592.00 | $2,592.00 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $296.08 / $2,592.00 / $3,993.75
| Professional | | $296.08 | $2,592.00 | $3,993.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $482.34
| Professional | | $100.00 | $200.00 | $482.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.47 / $501.56 / $2,737.91
| Professional | | $150.47 | $501.56 | $2,737.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.96 / $1,837.36 / $2,737.84
| Professional | | $1,177.96 | $1,837.36 | $2,737.84 |