- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,574.73 / $4,167.30 / $4,412.43
| Professional | | $2,574.73 | $4,167.30 | $4,412.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,517.50 / $3,517.50 / $3,517.50
| Professional | | $3,517.50 | $3,517.50 | $3,517.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,626.76 / $3,626.76 / $3,626.76
| Facility | | $3,626.76 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.52 / $3,626.76 / $5,715.00
| Professional | | $387.52 | $3,626.76 | $5,715.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.95 / $1,853.92 / $3,521.43
| Professional | | $1,235.95 | $1,853.92 | $3,521.43 |