- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.71 / $1,142.71 / $1,142.71
| Professional | | $1,142.71 | $1,142.71 | $1,142.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,813.00 / $2,176.00 / $4,350.00
| Professional | | $1,813.00 | $2,176.00 | $4,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,426.37 / $1,889.96 / $2,576.07
| Professional | | $1,426.37 | $1,889.96 | $2,576.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,624.71 / $2,759.76 / $4,436.51
| Professional | | $1,624.71 | $2,759.76 | $4,436.51 |