- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.60 / $1,737.60 / $1,737.60
| Professional | | $1,737.60 | $1,737.60 | $1,737.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,971.00 / $4,477.00 / $5,372.00
| Professional | | $3,971.00 | $4,477.00 | $5,372.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,516.21 / $2,633.15 / $4,290.55
| Professional | | $2,516.21 | $2,633.15 | $4,290.55 |
- 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
- $2,249.13 / $4,734.31 / $7,326.01
| Professional | | $2,249.13 | $4,734.31 | $7,326.01 |