- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.14 / $2,316.67 / $2,610.58
| Professional | | $1,830.14 | $2,316.67 | $2,610.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.89 / $314.00 / $314.00
| Professional | | $266.89 | $314.00 | $314.00 |
- 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
- $2,203.19 / $2,592.00 / $2,592.00
| Professional | | $2,203.19 | $2,592.00 | $2,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.94 / $1,573.72 / $2,653.33
| Professional | | $1,270.94 | $1,573.72 | $2,653.33 |