- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.70 / $1,232.39 / $1,547.09
| Professional | | $1,222.70 | $1,232.39 | $1,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,350.00 / $2,820.00 / $4,266.00
| Professional | | $2,350.00 | $2,820.00 | $4,266.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,668.23 / $2,464.77 / $3,389.79
| Professional | | $1,668.23 | $2,464.77 | $3,389.79 |
- 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
- $1,355.75 / $2,455.96 / $4,170.39
| Professional | | $1,355.75 | $2,455.96 | $4,170.39 |