- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.13 / $1,284.13 / $1,284.13
| Professional | | $1,284.13 | $1,284.13 | $1,284.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,276.00 / $2,731.00 / $3,986.00
| Professional | | $2,276.00 | $2,731.00 | $3,986.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.09 / $2,117.69 / $3,689.69
| Professional | | $1,745.09 | $2,117.69 | $3,689.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,984.95 / $3,266.87 / $5,206.07
| Professional | | $1,984.95 | $3,266.87 | $5,206.07 |