- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.82 / $2,063.44 / $2,550.04
| Professional | | $2,043.82 | $2,063.44 | $2,550.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,021.00 / $4,825.00 / $7,301.00
| Professional | | $4,021.00 | $4,825.00 | $7,301.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,723.07 / $4,026.88 / $5,663.59
| Professional | | $2,723.07 | $4,026.88 | $5,663.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,297.92 / $4,161.06 / $6,467.97
| Professional | | $2,297.92 | $4,161.06 | $6,467.97 |