- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,630.27 / $3,801.89
| Professional | | $2,041.74 | $2,630.27 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $4,466.84
| Professional | | $3,715.35 | $3,715.35 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,454.71 / $4,365.16
| Facility | | $2,187.76 | $2,454.71 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $15,135.61
| Professional | | $1,288.25 | $1,288.25 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,019.95
| Professional | | $1,288.25 | $1,288.25 | $3,019.95 |