- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,342.66 / $2,342.66 / $2,342.66
| Professional | | $2,342.66 | $2,342.66 | $2,342.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,352.00 / $6,035.00 / $7,242.00
| Professional | | $5,352.00 | $6,035.00 | $7,242.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,085.32 / $3,256.25 / $5,947.13
| Professional | | $3,085.32 | $3,256.25 | $5,947.13 |
- 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
- $2,766.88 / $7,301.79 / $9,934.32
| Professional | | $2,766.88 | $7,301.79 | $9,934.32 |