- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.06 / $1,980.06 / $1,980.06
| Professional | | $1,980.06 | $1,980.06 | $1,980.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,054.00 / $4,865.00 / $7,830.00
| Professional | | $4,054.00 | $4,865.00 | $7,830.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,548.34 / $3,280.52 / $4,721.71
| Professional | | $2,548.34 | $3,280.52 | $4,721.71 |
- 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
- $2,098.96 / $3,987.63 / $7,741.82
| Professional | | $2,098.96 | $3,987.63 | $7,741.82 |