- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,398.58 / $1,398.58 / $1,398.58
| Professional | | $1,398.58 | $1,398.58 | $1,398.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,728.00 / $6,027.00 / $7,232.00
| Professional | | $3,728.00 | $6,027.00 | $7,232.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.42 / $1,594.91 / $2,303.76
| Professional | | $1,181.42 | $1,594.91 | $2,303.76 |
- 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
- $1,207.46 / $2,485.21 / $4,046.88
| Professional | | $1,207.46 | $2,485.21 | $4,046.88 |