- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.33 / $1,256.33 / $1,256.33
| Professional | | $1,256.33 | $1,256.33 | $1,256.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,870.00 / $3,237.00 / $3,884.00
| Professional | | $2,870.00 | $3,237.00 | $3,884.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.35 / $1,936.32 / $3,043.41
| Professional | | $1,819.35 | $1,936.32 | $3,043.41 |
- 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
- $1,609.64 / $4,140.60 / $5,500.45
| Professional | | $1,609.64 | $4,140.60 | $5,500.45 |