- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.63 / $1,123.63 / $1,123.63
| Professional | | $1,123.63 | $1,123.63 | $1,123.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,569.00 / $2,897.00 / $3,476.00
| Professional | | $2,569.00 | $2,897.00 | $3,476.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.00 / $1,724.80 / $2,726.83
| Professional | | $1,618.00 | $1,724.80 | $2,726.83 |
- 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
- $1,472.73 / $3,029.50 / $5,141.38
| Professional | | $1,472.73 | $3,029.50 | $5,141.38 |