- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.40 / $1,171.63 / $1,739.40
| Professional | | $1,136.40 | $1,171.63 | $1,739.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,349.00 / $4,019.00 / $6,217.00
| Professional | | $3,349.00 | $4,019.00 | $6,217.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.21 / $2,127.86 / $2,992.09
| Professional | | $1,313.21 | $2,127.86 | $2,992.09 |
- 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
- $1,317.79 / $2,357.46 / $4,919.63
| Professional | | $1,317.79 | $2,357.46 | $4,919.63 |