- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.60 / $1,139.83 / $1,417.77
| Professional | | $1,123.60 | $1,139.83 | $1,417.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,428.80 / $2,428.80 / $2,428.80
| Facility | | $2,428.80 | $2,428.80 | $2,428.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,174.00 / $2,609.00 / $3,947.00
| Professional | | $2,174.00 | $2,609.00 | $3,947.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,546.29 / $2,279.67 / $3,112.85
| Professional | | $1,546.29 | $2,279.67 | $3,112.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,281.61 / $2,281.12 / $3,994.88
| Professional | | $1,281.61 | $2,281.12 | $3,994.88 |