- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.24 / $719.56 / $910.62
| Professional | | $719.24 | $719.56 | $910.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.20 / $2,767.20 / $2,767.20
| Facility | | $2,767.20 | $2,767.20 | $2,767.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,652.00 / $2,501.00
| Professional | | $1,377.00 | $1,652.00 | $2,501.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.17 / $1,438.48 / $1,994.71
| Professional | | $970.17 | $1,438.48 | $1,994.71 |
- 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
- $1,001.07 / $1,225.80 / $2,293.19
| Professional | | $1,001.07 | $1,225.80 | $2,293.19 |