- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,771.03 / $1,771.03 / $1,771.03
| Professional | | $1,771.03 | $1,771.03 | $1,771.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,831.00 / $5,662.00 / $6,794.00
| Professional | | $2,831.00 | $5,662.00 | $6,794.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,361.54 / $2,939.91 / $4,224.21
| Professional | | $2,361.54 | $2,939.91 | $4,224.21 |
- 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
- $2,665.30 / $5,439.42 / $7,093.68
| Professional | | $2,665.30 | $5,439.42 | $7,093.68 |