- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,715.16 / $2,715.16 / $3,393.95
| Professional | | $2,715.16 | $2,715.16 | $3,393.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $2,828.24 / $5,328.00
| Facility | | $55.00 | $2,828.24 | $5,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,284.00 / $3,083.31 / $14,489.00
| Professional | | $2,284.00 | $3,083.31 | $14,489.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,497.21 / $2,284.00 / $3,155.87
| Facility | | $1,497.21 | $2,284.00 | $3,155.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.38 / $2,617.46 / $3,460.70
| Professional | | $1,520.38 | $2,617.46 | $3,460.70 |