- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $912.01 / $1,584.89
| Professional | | $831.76 | $912.01 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,162.28 / $3,162.28
| Professional | | $2,089.30 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $1,862.09
| Professional | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $25,703.96
| Facility | | $6,918.31 | $6,918.31 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,621.81 / $3,467.37
| Professional | | $1,000.00 | $1,621.81 | $3,467.37 |