- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,830.47 / $2,830.47 / $2,830.47
| Professional | | $2,830.47 | $2,830.47 | $2,830.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,794.00 / $6,953.00 / $11,191.00
| Professional | | $5,794.00 | $6,953.00 | $11,191.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,655.52 / $4,682.52 / $6,848.33
| Professional | | $3,655.52 | $4,682.52 | $6,848.33 |
- 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
- $3,223.05 / $6,937.97 / $11,099.87
| Professional | | $3,223.05 | $6,937.97 | $11,099.87 |