- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.81 / $1,037.81 / $1,037.81
| Professional | | $1,037.81 | $1,037.81 | $1,037.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,834.00 / $2,201.00 / $3,211.00
| Professional | | $1,834.00 | $2,201.00 | $3,211.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.75 / $1,707.84 / $2,039.65
| Professional | | $1,134.75 | $1,707.84 | $2,039.65 |
- 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
- $1,292.49 / $2,145.44 / $3,626.03
| Professional | | $1,292.49 | $2,145.44 | $3,626.03 |