- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,668.22 / $1,668.22 / $1,668.22
| Professional | | $1,668.22 | $1,668.22 | $1,668.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,481.10 / $6,651.58 / $8,948.50
| Facility | | $5,481.10 | $6,651.58 | $8,948.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.87 / $445.03 / $528.09
| Professional | | $324.87 | $445.03 | $528.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,568.00 / $2,568.00 / $2,568.00
| Facility | | $2,568.00 | $2,568.00 | $2,568.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.95 / $394.46 / $591.69
| Professional | | $287.95 | $394.46 | $591.69 |