- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,765.81 / $2,765.81 / $3,457.26
| Professional | | $2,765.81 | $2,765.81 | $3,457.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $2,882.64 / $5,432.86
| Facility | | $55.00 | $2,882.64 | $5,432.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,319.62 / $2,964.63 / $13,636.00
| Professional | | $2,319.62 | $2,964.63 | $13,636.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,598.50 / $2,319.62 / $3,108.09
| Facility | | $1,598.50 | $2,319.62 | $3,108.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.67 / $2,648.27 / $3,526.27
| Professional | | $1,550.67 | $2,648.27 | $3,526.27 |