- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,353.62 / $1,353.62 / $1,353.62
| Professional | | $1,353.62 | $1,353.62 | $1,353.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,069.00 / $3,460.00 / $4,152.00
| Professional | | $3,069.00 | $3,460.00 | $4,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,193.50 / $2,259.27 / $3,836.13
| Professional | | $2,193.50 | $2,259.27 | $3,836.13 |
- 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
- $2,383.80 / $3,976.53 / $6,324.11
| Professional | | $2,383.80 | $3,976.53 | $6,324.11 |