- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,739.69 / $1,739.69 / $1,739.69
| Professional | | $1,739.69 | $1,739.69 | $1,739.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,979.00 / $4,487.00 / $5,384.00
| Professional | | $3,979.00 | $4,487.00 | $5,384.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,473.07 / $2,473.77 / $4,167.16
| Professional | | $2,473.07 | $2,473.77 | $4,167.16 |
- 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
- $2,136.85 / $5,514.30 / $7,080.49
| Professional | | $2,136.85 | $5,514.30 | $7,080.49 |