- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $2,754.23
| Professional | | $2,630.27 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,311.31 / $3,311.31
| Professional | | $2,137.96 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,467.37 / $3,467.37
| Professional | | $2,951.21 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $3,090.30 / $4,168.69
| Facility | | $407.38 | $3,090.30 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,162.28 / $5,370.32
| Professional | | $2,454.71 | $3,162.28 | $5,370.32 |