- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.18 / $1,094.18 / $1,094.18
| Professional | | $1,094.18 | $1,094.18 | $1,094.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,976.00 / $2,371.00 / $3,461.00
| Professional | | $1,976.00 | $2,371.00 | $3,461.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.94 / $1,831.63 / $2,568.12
| Professional | | $1,479.94 | $1,831.63 | $2,568.12 |
- 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
- $1,718.20 / $2,453.46 / $4,264.89
| Professional | | $1,718.20 | $2,453.46 | $4,264.89 |