- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.08 / $1,392.08 / $1,392.08
| Professional | | $1,392.08 | $1,392.08 | $1,392.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,188.00 / $3,595.00 / $4,314.00
| Professional | | $3,188.00 | $3,595.00 | $4,314.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.07 / $2,038.09 / $3,313.88
| Professional | | $1,946.07 | $2,038.09 | $3,313.88 |
- 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
- $1,665.03 / $3,562.36 / $5,582.28
| Professional | | $1,665.03 | $3,562.36 | $5,582.28 |