- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,863.36 / $3,863.36 / $3,863.36
| Professional | | $3,863.36 | $3,863.36 | $3,863.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,488.00 / $4,978.93 / $4,978.93
| Facility | | $4,488.00 | $4,978.93 | $4,978.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $725.31 / $4,232.09 / $14,873.44
| Professional | | $725.31 | $4,232.09 | $14,873.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,322.48 / $4,095.56 / $6,492.96
| Professional | | $2,322.48 | $4,095.56 | $6,492.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,506.55 / $3,063.56 / $5,570.10
| Professional | | $2,506.55 | $3,063.56 | $5,570.10 |