- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.95 / $1,747.95 / $3,846.00
| Professional | | $1,747.95 | $1,747.95 | $3,846.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,394.10 / $3,394.10 / $3,394.10
| Professional | | $3,394.10 | $3,394.10 | $3,394.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,446.40
| Facility | | $2,446.40 | $2,446.40 | $2,446.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $3,331.31
| Professional | | $2,446.40 | $2,446.40 | $3,331.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.76 / $1,845.00 / $3,075.00
| Professional | | $1,435.76 | $1,845.00 | $3,075.00 |