- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,090.30 / $4,897.79
| Professional | | $2,884.03 | $3,090.30 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,630.78 / $3,630.78
| Professional | | $3,090.30 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Professional | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $5,495.41
| Facility | | $2,884.03 | $2,884.03 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Professional | | $3,019.95 | $3,019.95 | $3,019.95 |