- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,451.50 / $2,489.53 / $3,117.96
| Professional | | $2,451.50 | $2,489.53 | $3,117.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,734.00 / $5,681.00 / $8,594.00
| Professional | | $4,734.00 | $5,681.00 | $8,594.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,416.54 / $4,979.07 / $6,799.44
| Professional | | $3,416.54 | $4,979.07 | $6,799.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,509.00 / $8,509.00 / $27,952.00
| Facility | | $8,509.00 | $8,509.00 | $27,952.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,531.92 / $4,324.81 / $9,275.48
| Professional | | $3,531.92 | $4,324.81 | $9,275.48 |