- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,226.54 / $2,917.72 / $3,324.85
| Professional | | $2,226.54 | $2,917.72 | $3,324.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,468.09 / $2,682.71 / $2,682.71
| Professional | | $2,468.09 | $2,682.71 | $2,682.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,399.94 / $2,399.94 / $4,012.16
| Facility | | $2,399.94 | $2,399.94 | $4,012.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.16 / $2,399.94 / $4,777.50
| Professional | | $326.16 | $2,399.94 | $4,777.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.08 / $2,080.50 / $3,223.07
| Professional | | $1,357.08 | $2,080.50 | $3,223.07 |