- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,034.61 / $2,034.61 / $2,034.61
| Professional | | $2,034.61 | $2,034.61 | $2,034.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,652.00 / $5,246.00 / $6,295.00
| Professional | | $4,652.00 | $5,246.00 | $6,295.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,933.69 / $2,956.21 / $4,878.39
| Professional | | $2,933.69 | $2,956.21 | $4,878.39 |
- 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
- $2,511.08 / $5,336.06 / $8,268.50
| Professional | | $2,511.08 | $5,336.06 | $8,268.50 |