- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.81 / $1,518.62 / $1,518.62
| Professional | | $1,380.81 | $1,518.62 | $1,518.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,653.00 / $3,537.00 / $4,244.00
| Professional | | $2,653.00 | $3,537.00 | $4,244.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,525.08 / $1,871.01 / $2,734.11
| Professional | | $1,525.08 | $1,871.01 | $2,734.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,674.12 / $2,660.22 / $4,721.60
| Professional | | $1,674.12 | $2,660.22 | $4,721.60 |