- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.10 / $788.56 / $998.06
| Professional | | $788.10 | $788.56 | $998.06 |
- 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
- $1,510.00 / $1,812.00 / $2,741.00
| Professional | | $1,510.00 | $1,812.00 | $2,741.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,065.74 / $1,576.20 / $2,185.28
| Professional | | $1,065.74 | $1,576.20 | $2,185.28 |
- 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
- $844.36 / $1,563.01 / $2,444.00
| Professional | | $844.36 | $1,563.01 | $2,444.00 |