- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,615.72 / $1,615.72 / $1,615.72
| Professional | | $1,615.72 | $1,615.72 | $1,615.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,673.00 / $4,142.00 / $4,970.00
| Professional | | $3,673.00 | $4,142.00 | $4,970.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,287.48 / $2,323.63 / $3,877.72
| Professional | | $2,287.48 | $2,323.63 | $3,877.72 |
- 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
- $1,931.28 / $5,192.00 / $6,610.55
| Professional | | $1,931.28 | $5,192.00 | $6,610.55 |