- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.52 / $1,175.52 / $1,175.52
| Professional | | $1,175.52 | $1,175.52 | $1,175.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,696.00 / $3,040.00 / $3,648.00
| Professional | | $2,696.00 | $3,040.00 | $3,648.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,638.41 / $1,640.37 / $2,792.24
| Professional | | $1,638.41 | $1,640.37 | $2,792.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,732.00 / $12,732.00 / $31,027.00
| Facility | | $12,732.00 | $12,732.00 | $31,027.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,834.80 / $3,669.60 / $4,705.80
| Professional | | $1,834.80 | $3,669.60 | $4,705.80 |