- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.17 / $1,428.17 / $1,428.17
| Professional | | $1,428.17 | $1,428.17 | $1,428.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,246.00 / $3,661.00 / $4,393.00
| Professional | | $3,246.00 | $3,661.00 | $4,393.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,020.14 / $2,027.72 / $3,254.25
| Professional | | $2,020.14 | $2,027.72 | $3,254.25 |
- 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
- $1,732.32 / $4,526.50 / $5,833.07
| Professional | | $1,732.32 | $4,526.50 | $5,833.07 |