- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.38 / $1,531.38 / $1,531.38
| Professional | | $1,531.38 | $1,531.38 | $1,531.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,507.00 / $3,955.00 / $4,746.00
| Professional | | $3,507.00 | $3,955.00 | $4,746.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,153.98 / $2,162.00 / $3,648.99
| Professional | | $2,153.98 | $2,162.00 | $3,648.99 |
- 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
- $1,873.48 / $4,829.00 / $6,177.60
| Professional | | $1,873.48 | $4,829.00 | $6,177.60 |