- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,986.71 / $2,483.38 / $4,158.88
| Professional | | $1,986.71 | $2,483.38 | $4,158.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,009.95 / $18,009.95 / $18,009.95
| Facility | | $18,009.95 | $18,009.95 | $18,009.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.00 / $6,677.33 / $6,677.33
| Professional | | $1,386.00 | $6,677.33 | $6,677.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,085.19 / $1,386.00 / $1,406.40
| Facility | | $1,085.19 | $1,386.00 | $1,406.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.19 / $1,406.40 / $1,876.63
| Professional | | $1,085.19 | $1,406.40 | $1,876.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $942.00 / $2,409.90
| Professional | | $5.00 | $942.00 | $2,409.90 |