- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.73 / $1,381.73 / $1,381.73
| Professional | | $1,381.73 | $1,381.73 | $1,381.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,166.00 / $3,571.00 / $4,285.00
| Professional | | $3,166.00 | $3,571.00 | $4,285.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.75 / $1,936.72 / $3,290.26
| Professional | | $1,932.75 | $1,936.72 | $3,290.26 |
- 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
- $2,164.80 / $3,544.09 / $5,822.53
| Professional | | $2,164.80 | $3,544.09 | $5,822.53 |