- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,636.11 / $1,636.11 / $1,636.11
| Professional | | $1,636.11 | $1,636.11 | $1,636.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,187.00 / $3,824.00 / $4,780.00
| Professional | | $3,187.00 | $3,824.00 | $4,780.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.37 / $2,730.12 / $3,876.10
| Professional | | $2,225.37 | $2,730.12 | $3,876.10 |
- 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
- $2,539.35 / $4,076.95 / $6,357.12
| Professional | | $2,539.35 | $4,076.95 | $6,357.12 |