- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.14 / $785.40 / $1,004.62
| Professional | | $784.14 | $785.40 | $1,004.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.20 / $2,767.20 / $2,767.20
| Facility | | $2,767.20 | $2,767.20 | $2,767.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,612.00 / $1,934.00 / $3,115.00
| Professional | | $1,612.00 | $1,934.00 | $3,115.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.14 / $1,603.11 / $2,009.97
| Professional | | $986.14 | $1,603.11 | $2,009.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $6,489.22 / $14,634.00
| Facility | | $4,200.00 | $6,489.22 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.63 / $1,587.39 / $2,620.80
| Professional | | $854.63 | $1,587.39 | $2,620.80 |