- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.57 / $1,057.73 / $1,580.63
| Professional | | $1,022.57 | $1,057.73 | $1,580.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,014.00 / $3,617.00 / $5,596.00
| Professional | | $3,014.00 | $3,617.00 | $5,596.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.11 / $1,918.21 / $2,686.22
| Professional | | $1,178.11 | $1,918.21 | $2,686.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.33 / $2,144.34 / $4,428.59
| Professional | | $1,185.33 | $2,144.34 | $4,428.59 |