- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,633.12 / $1,633.12 / $1,633.12
| Professional | | $1,633.12 | $1,633.12 | $1,633.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,577.00 / $5,154.00 / $6,185.00
| Professional | | $2,577.00 | $5,154.00 | $6,185.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.35 / $2,687.58 / $3,610.88
| Professional | | $2,005.35 | $2,687.58 | $3,610.88 |
- 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
- $2,285.25 / $3,884.41 / $6,247.56
| Professional | | $2,285.25 | $3,884.41 | $6,247.56 |