- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.96 / $1,083.96 / $1,083.96
| Professional | | $1,083.96 | $1,083.96 | $1,083.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,563.00 / $1,563.00 / $1,928.00
| Professional | | $1,563.00 | $1,563.00 | $1,928.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.11 / $1,508.45 / $2,282.69
| Professional | | $1,463.11 | $1,508.45 | $2,282.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.57 / $2,123.16 / $4,154.80
| Professional | | $1,313.57 | $2,123.16 | $4,154.80 |