- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.15 / $1,311.15 / $1,311.15
| Professional | | $1,311.15 | $1,311.15 | $1,311.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,006.00 / $3,390.00 / $4,068.00
| Professional | | $3,006.00 | $3,390.00 | $4,068.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.03 / $1,787.81 / $3,117.50
| Professional | | $1,698.03 | $1,787.81 | $3,117.50 |
- 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
- $1,532.90 / $3,300.90 / $5,166.47
| Professional | | $1,532.90 | $3,300.90 | $5,166.47 |