- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,387.78 / $1,416.95 / $1,762.48
| Professional | | $1,387.78 | $1,416.95 | $1,762.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.00 / $3,206.00 / $4,850.00
| Professional | | $2,672.00 | $3,206.00 | $4,850.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,894.30 / $2,833.91 / $3,874.59
| Professional | | $1,894.30 | $2,833.91 | $3,874.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.10 / $2,763.12 / $5,573.09
| Professional | | $1,639.10 | $2,763.12 | $5,573.09 |