- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,099.08 / $1,099.08 / $1,099.08
| Professional | | $1,099.08 | $1,099.08 | $1,099.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.00 / $2,575.00 / $3,220.00
| Professional | | $2,146.00 | $2,575.00 | $3,220.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,509.33 / $1,839.47 / $2,639.74
| Professional | | $1,509.33 | $1,839.47 | $2,639.74 |
- 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
- $1,714.35 / $2,831.14 / $4,279.43
| Professional | | $1,714.35 | $2,831.14 | $4,279.43 |