- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.26 / $1,136.26 / $1,136.26
| Professional | | $1,136.26 | $1,136.26 | $1,136.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,053.00 / $2,464.00 / $3,595.00
| Professional | | $2,053.00 | $2,464.00 | $3,595.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.22 / $1,871.62 / $2,652.66
| Professional | | $1,530.22 | $1,871.62 | $2,652.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,716.54 / $2,838.59 / $4,515.72
| Professional | | $1,716.54 | $2,838.59 | $4,515.72 |