- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.65 / $3,027.96 / $3,503.16
| Professional | | $1,908.65 | $3,027.96 | $3,503.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,006.50 / $3,006.50 / $3,006.50
| Professional | | $3,006.50 | $3,006.50 | $3,006.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.05 / $2,225.05 / $2,225.05
| Facility | | $2,225.05 | $2,225.05 | $2,225.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.68 / $2,225.05 / $5,261.25
| Professional | | $343.68 | $2,225.05 | $5,261.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.36 / $1,478.44 / $3,073.89
| Professional | | $955.36 | $1,478.44 | $3,073.89 |