- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.86 / $843.45 / $1,064.10
| Professional | | $828.86 | $843.45 | $1,064.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,767.20 / $2,767.20 / $2,767.20
| Facility | | $2,767.20 | $2,767.20 | $2,767.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.00 / $1,906.00 / $2,882.00
| Professional | | $1,588.00 | $1,906.00 | $2,882.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.57 / $1,505.36 / $2,317.63
| Professional | | $1,003.57 | $1,505.36 | $2,317.63 |
- 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
- $830.40 / $1,567.20 / $2,471.28
| Professional | | $830.40 | $1,567.20 | $2,471.28 |