- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.35 / $1,140.35 / $1,140.35
| Professional | | $1,140.35 | $1,140.35 | $1,140.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,226.00 / $2,671.00 / $3,338.00
| Professional | | $2,226.00 | $2,671.00 | $3,338.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.33 / $1,907.68 / $2,713.79
| Professional | | $1,549.33 | $1,907.68 | $2,713.79 |
- 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
- $1,801.25 / $2,880.09 / $4,460.28
| Professional | | $1,801.25 | $2,880.09 | $4,460.28 |