- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.08 / $1,277.08 / $1,277.08
| Professional | | $1,277.08 | $1,277.08 | $1,277.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,244.00 / $2,693.00 / $3,930.00
| Professional | | $2,244.00 | $2,693.00 | $3,930.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.49 / $2,024.05 / $2,318.16
| Professional | | $1,275.49 | $2,024.05 | $2,318.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,464.66 / $2,664.54 / $4,014.11
| Professional | | $1,464.66 | $2,664.54 | $4,014.11 |