- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,031.86 / $2,031.86 / $2,031.86
| Professional | | $2,031.86 | $2,031.86 | $2,031.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,644.00 / $5,237.00 / $6,284.00
| Professional | | $4,644.00 | $5,237.00 | $6,284.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,883.53 / $3,021.67 / $4,874.64
| Professional | | $2,883.53 | $3,021.67 | $4,874.64 |
- 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
- $2,443.82 / $6,425.11 / $8,222.27
| Professional | | $2,443.82 | $6,425.11 | $8,222.27 |