- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $467.74
| Professional | | $371.54 | $371.54 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $16,595.87
| Facility | | $16,595.87 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,089.30 / $2,187.76
| Professional | | $1,318.26 | $2,089.30 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Professional | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Professional | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Professional | | $1,995.26 | $1,995.26 | $1,995.26 |