- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,354.63 / $2,354.63 / $2,354.63
| Professional | | $2,354.63 | $2,354.63 | $2,354.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,818.00 / $5,782.00 / $9,307.00
| Professional | | $4,818.00 | $5,782.00 | $9,307.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,032.62 / $3,896.49 / $5,681.38
| Professional | | $3,032.62 | $3,896.49 | $5,681.38 |
- 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
- $3,397.35 / $5,295.71 / $9,216.26
| Professional | | $3,397.35 | $5,295.71 | $9,216.26 |