- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.33 / $1,042.73 / $1,296.54
| Professional | | $1,021.33 | $1,042.73 | $1,296.54 |
- 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
- $1,978.00 / $2,374.00 / $3,592.00
| Professional | | $1,978.00 | $2,374.00 | $3,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.16 / $2,083.67 / $2,840.56
| Professional | | $1,412.16 | $2,083.67 | $2,840.56 |
- 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
- $1,134.69 / $1,909.05 / $3,396.90
| Professional | | $1,134.69 | $1,909.05 | $3,396.90 |