- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.08 / $1,087.08 / $1,087.08
| Professional | | $1,087.08 | $1,087.08 | $1,087.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.00 / $2,406.00 / $3,610.00
| Professional | | $2,005.00 | $2,406.00 | $3,610.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.84 / $1,798.84 / $2,414.05
| Professional | | $1,408.84 | $1,798.84 | $2,414.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,576.30 / $2,604.54 / $4,164.60
| Professional | | $1,576.30 | $2,604.54 | $4,164.60 |