- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.75 / $3,548.75 / $3,548.75
| Professional | | $3,548.75 | $3,548.75 | $3,548.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.00 / $2,906.00 / $3,487.00
| Professional | | $1,453.00 | $2,906.00 | $3,487.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.81 / $1,517.31 / $2,045.59
| Professional | | $1,108.81 | $1,517.31 | $2,045.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.30 / $2,175.42 / $3,523.07
| Professional | | $1,268.30 | $2,175.42 | $3,523.07 |