- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,169.19 / $2,169.19 / $2,169.19
| Professional | | $2,169.19 | $2,169.19 | $2,169.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,442.00 / $5,330.00 / $8,580.00
| Professional | | $4,442.00 | $5,330.00 | $8,580.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,774.07 / $3,593.52 / $4,996.89
| Professional | | $2,774.07 | $3,593.52 | $4,996.89 |
- 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
- $3,108.05 / $6,216.11 / $8,466.46
| Professional | | $3,108.05 | $6,216.11 | $8,466.46 |