- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,820.32 / $2,305.73 / $2,882.17
| Professional | | $1,820.32 | $2,305.73 | $2,882.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.22 / $1,274.22 / $3,640.77
| Professional | | $1,274.22 | $1,274.22 | $3,640.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.72 / $3,715.72 / $4,399.10
| Professional | | $3,715.72 | $3,715.72 | $4,399.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,305.73 / $3,033.86 / $4,256.25
| Facility | | $2,305.73 | $3,033.86 | $4,256.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,427.09 / $4,156.39 / $5,309.26
| Professional | | $2,427.09 | $4,156.39 | $5,309.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.22 / $1,274.22 / $1,820.32
| Professional | | $1,274.22 | $1,274.22 | $1,820.32 |