- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,019.95 / $5,888.44
| Professional | | $2,570.40 | $3,019.95 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $10,000.00
| Professional | | $3,715.35 | $3,715.35 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,570.88 / $11,220.18
| Professional | | $2,454.71 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,073.80 / $7,244.36
| Professional | | $3,019.95 | $4,073.80 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,981.07 / $6,918.31
| Professional | | $3,019.95 | $3,981.07 | $6,918.31 |