- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.66 / $1,286.66 / $1,286.66
| Professional | | $1,286.66 | $1,286.66 | $1,286.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,508.00 / $3,010.00 / $3,761.00
| Professional | | $2,508.00 | $3,010.00 | $3,761.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,766.26 / $2,149.39 / $3,046.08
| Professional | | $1,766.26 | $2,149.39 | $3,046.08 |
- 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
- $2,028.40 / $3,255.25 / $5,058.24
| Professional | | $2,028.40 | $3,255.25 | $5,058.24 |