- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,280.58 / $1,280.58 / $1,280.58
| Professional | | $1,280.58 | $1,280.58 | $1,280.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,010.00 / $3,395.00 / $4,074.00
| Professional | | $3,010.00 | $3,395.00 | $4,074.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.31 / $1,497.90 / $2,529.67
| Professional | | $1,214.31 | $1,497.90 | $2,529.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $10,811.40 / $26,502.00
| Facility | | $6,934.00 | $10,811.40 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.71 / $2,721.41 / $4,349.39
| Professional | | $1,360.71 | $2,721.41 | $4,349.39 |