- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,438.43 / $1,438.43 / $1,438.43
| Professional | | $1,438.43 | $1,438.43 | $1,438.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,287.00 / $3,707.00 / $4,448.00
| Professional | | $3,287.00 | $3,707.00 | $4,448.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,139.65 / $2,247.79 / $3,575.47
| Professional | | $2,139.65 | $2,247.79 | $3,575.47 |
- 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
- $1,866.38 / $4,746.97 / $6,259.43
| Professional | | $1,866.38 | $4,746.97 | $6,259.43 |