- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.74 / $2,039.74 / $3,611.32
| Professional | | $2,039.74 | $2,039.74 | $3,611.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,960.65 / $3,960.65 / $3,960.65
| Professional | | $3,960.65 | $3,960.65 | $3,960.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $4,675.53
| Facility | | $2,672.64 | $2,672.64 | $4,675.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,672.64 / $2,672.64 / $2,672.64
| Professional | | $2,672.64 | $2,672.64 | $2,672.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,589.10 / $1,878.03 / $2,824.38
| Professional | | $1,589.10 | $1,878.03 | $2,824.38 |