- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,123.69 / $2,851.83 / $2,851.83
| Professional | | $2,123.69 | $2,851.83 | $2,851.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,375.63 / $6,826.19 / $6,860.32
| Professional | | $5,375.63 | $6,826.19 | $6,860.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,486.13 / $3,486.13 / $4,357.67
| Professional | | $3,486.13 | $3,486.13 | $4,357.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,820.32 / $2,184.38 / $2,882.17
| Facility | | $1,820.32 | $2,184.38 | $2,882.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,820.32 / $3,883.34 / $15,108.62
| Professional | | $1,820.32 | $3,883.34 | $15,108.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.22 / $3,094.54 / $4,666.08
| Professional | | $1,274.22 | $3,094.54 | $4,666.08 |