- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,597.33 / $1,597.33 / $1,597.33
| Professional | | $1,597.33 | $1,597.33 | $1,597.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,271.00 / $3,925.00 / $6,319.00
| Professional | | $3,271.00 | $3,925.00 | $6,319.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,970.30 / $2,650.74 / $3,819.58
| Professional | | $1,970.30 | $2,650.74 | $3,819.58 |
- 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
- $2,206.60 / $4,413.20 / $5,215.59
| Professional | | $2,206.60 | $4,413.20 | $5,215.59 |