- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.97 / $1,252.97 / $1,252.97
| Professional | | $1,252.97 | $1,252.97 | $1,252.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,579.00 / $3,095.00 / $5,306.00
| Professional | | $2,579.00 | $3,095.00 | $5,306.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,622.13 / $2,076.92 / $2,860.55
| Professional | | $1,622.13 | $2,076.92 | $2,860.55 |
- 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
- $1,815.54 / $3,631.09 / $4,704.47
| Professional | | $1,815.54 | $3,631.09 | $4,704.47 |