- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.16 / $1,055.73 / $1,324.75
| Professional | | $1,041.16 | $1,055.73 | $1,324.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,007.00 / $2,408.00 / $3,643.00
| Professional | | $2,007.00 | $2,408.00 | $3,643.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,442.27 / $2,111.46 / $2,889.52
| Professional | | $1,442.27 | $2,111.46 | $2,889.52 |
- 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
- $1,309.79 / $2,109.78 / $3,691.99
| Professional | | $1,309.79 | $2,109.78 | $3,691.99 |