- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.17 / $1,015.17 / $1,015.17
| Professional | | $1,015.17 | $1,015.17 | $1,015.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,984.00 / $2,381.00 / $2,976.00
| Professional | | $1,984.00 | $2,381.00 | $2,976.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.27 / $1,701.21 / $2,375.85
| Professional | | $1,370.27 | $1,701.21 | $2,375.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,585.10 / $3,165.78 / $4,085.39
| Professional | | $1,585.10 | $3,165.78 | $4,085.39 |