- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.66 / $1,329.66 / $1,329.66
| Professional | | $1,329.66 | $1,329.66 | $1,329.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,452.00 / $2,942.00 / $4,415.00
| Professional | | $2,452.00 | $2,942.00 | $4,415.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,762.54 / $2,197.94 / $3,012.32
| Professional | | $1,762.54 | $2,197.94 | $3,012.32 |
- 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
- $1,970.10 / $3,251.12 / $5,186.29
| Professional | | $1,970.10 | $3,251.12 | $5,186.29 |