- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.48 / $984.78 / $1,242.44
| Professional | | $979.48 | $984.78 | $1,242.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,116.00 / $6,116.00 / $6,116.00
| Facility | | $6,116.00 | $6,116.00 | $6,116.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,880.00 / $2,256.00 / $3,413.00
| Professional | | $1,880.00 | $2,256.00 | $3,413.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.56 / $1,969.57 / $2,716.25
| Professional | | $1,331.56 | $1,969.57 | $2,716.25 |
- 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
- $1,077.86 / $1,955.86 / $3,312.39
| Professional | | $1,077.86 | $1,955.86 | $3,312.39 |