- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.20 / $2,775.00 / $2,812.50
| Professional | | $1,898.20 | $2,775.00 | $2,812.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,000.00 / $3,000.00 / $3,420.00
| Professional | | $3,000.00 | $3,000.00 | $3,420.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.16 / $2,665.97 / $10,831.78
| Professional | | $2,053.16 | $2,665.97 | $10,831.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,750.00 / $4,500.00 / $5,625.00
| Professional | | $3,750.00 | $4,500.00 | $5,625.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.53 / $1,687.50 / $2,920.30
| Professional | | $1,226.53 | $1,687.50 | $2,920.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,875.00 / $1,875.00 / $1,875.00
| Professional | | $1,875.00 | $1,875.00 | $1,875.00 |