- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.03 / $1,168.03 / $1,168.03
| Professional | | $1,168.03 | $1,168.03 | $1,168.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,155.00 / $2,586.00 / $3,880.00
| Professional | | $2,155.00 | $2,586.00 | $3,880.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,540.56 / $1,931.89 / $2,648.83
| Professional | | $1,540.56 | $1,931.89 | $2,648.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,722.05 / $3,444.10 / $4,535.51
| Professional | | $1,722.05 | $3,444.10 | $4,535.51 |