- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.92 / $1,343.60 / $2,009.62
| Professional | | $1,298.92 | $1,343.60 | $2,009.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,819.00 / $4,583.00 / $7,090.00
| Professional | | $3,819.00 | $4,583.00 | $7,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,493.81 / $2,429.96 / $3,370.29
| Professional | | $1,493.81 | $2,429.96 | $3,370.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,502.56 / $2,568.61 / $4,908.79
| Professional | | $1,502.56 | $2,568.61 | $4,908.79 |