- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,904.56 / $1,904.56 / $1,904.56
| Professional | | $1,904.56 | $1,904.56 | $1,904.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,034.00 / $6,068.00 / $7,282.00
| Professional | | $3,034.00 | $6,068.00 | $7,282.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,447.23 / $3,155.19 / $4,364.35
| Professional | | $2,447.23 | $3,155.19 | $4,364.35 |
- 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
- $2,164.81 / $4,665.42 / $7,465.93
| Professional | | $2,164.81 | $4,665.42 | $7,465.93 |