- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.52 / $1,168.25 / $1,489.76
| Professional | | $1,141.52 | $1,168.25 | $1,489.76 |
- 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
- $2,165.00 / $2,598.00 / $3,930.00
| Professional | | $2,165.00 | $2,598.00 | $3,930.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,446.96 / $2,170.44 / $3,177.86
| Professional | | $1,446.96 | $2,170.44 | $3,177.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.94 / $2,299.94 / $3,857.10
| Professional | | $1,288.94 | $2,299.94 | $3,857.10 |