- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,280.10 / $1,280.10 / $1,280.10
| Professional | | $1,280.10 | $1,280.10 | $1,280.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,279.00 / $2,735.00 / $3,991.00
| Professional | | $2,279.00 | $2,735.00 | $3,991.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,599.32 / $2,119.39 / $3,022.13
| Professional | | $1,599.32 | $2,119.39 | $3,022.13 |
- 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
- $1,411.15 / $2,803.43 / $4,977.72
| Professional | | $1,411.15 | $2,803.43 | $4,977.72 |