- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.96 / $1,136.96 / $1,136.96
| Professional | | $1,136.96 | $1,136.96 | $1,136.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,219.00 / $2,663.00 / $3,328.00
| Professional | | $2,219.00 | $2,663.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.58 / $1,901.53 / $2,671.56
| Professional | | $1,544.58 | $1,901.53 | $2,671.56 |
- 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
- $1,801.81 / $2,554.35 / $4,451.05
| Professional | | $1,801.81 | $2,554.35 | $4,451.05 |