- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,889.81 / $1,889.81 / $1,889.81
| Professional | | $1,889.81 | $1,889.81 | $1,889.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,682.00 / $4,418.00 / $5,522.00
| Professional | | $3,682.00 | $4,418.00 | $5,522.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.54 / $3,154.29 / $4,506.59
| Professional | | $2,570.54 | $3,154.29 | $4,506.59 |
- 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
- $3,005.74 / $4,248.97 / $7,411.79
| Professional | | $3,005.74 | $4,248.97 | $7,411.79 |