- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.60 / $1,228.07 / $1,613.08
| Professional | | $1,215.60 | $1,228.07 | $1,613.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,502.00 / $3,002.00 / $4,832.00
| Professional | | $2,502.00 | $3,002.00 | $4,832.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,558.46 / $2,350.53 / $3,127.33
| Professional | | $1,558.46 | $2,350.53 | $3,127.33 |
- 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
- $1,799.77 / $2,203.80 / $4,046.88
| Professional | | $1,799.77 | $2,203.80 | $4,046.88 |