- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,619.83 / $2,183.59 / $2,310.61
| Professional | | $1,619.83 | $2,183.59 | $2,310.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,362.23 / $2,779.11 / $2,779.11
| Professional | | $2,362.23 | $2,779.11 | $2,779.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $3,248.38
| Facility | | $3,248.38 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,761.12 / $3,248.38 / $3,248.38
| Professional | | $2,761.12 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,004.65 / $3,003.60 / $5,408.88
| Professional | | $2,004.65 | $3,003.60 | $5,408.88 |