- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,452.39 / $2,452.39 / $2,452.39
| Professional | | $2,452.39 | $2,452.39 | $2,452.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,363.00 / $5,236.00 / $7,642.00
| Professional | | $4,363.00 | $5,236.00 | $7,642.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,116.28 / $4,049.62 / $5,759.42
| Professional | | $3,116.28 | $4,049.62 | $5,759.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,530.45 / $5,977.65 / $9,605.65
| Professional | | $3,530.45 | $5,977.65 | $9,605.65 |