- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.35 / $2,188.89 / $2,771.82
| Professional | | $1,077.35 | $2,188.89 | $2,771.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,615.35 / $13,152.00 / $26,542.00
| Facility | | $1,615.35 | $13,152.00 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,790.76 / $3,018.40 / $3,018.40
| Professional | | $2,790.76 | $3,018.40 | $3,018.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $570.25 / $785.92 / $1,181.52
| Facility | | $570.25 | $785.92 | $1,181.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.00 / $1,010.20 / $1,154.50
| Professional | | $4.00 | $1,010.20 | $1,154.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $586.12 / $787.40 / $1,181.52
| Facility | | $586.12 | $787.40 | $1,181.52 |