- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,243.46 / $2,520.30 / $2,673.12
| Professional | | $2,243.46 | $2,520.30 | $2,673.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.45 / $2,245.57 / $2,245.57
| Professional | | $1,675.45 | $2,245.57 | $2,245.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Facility | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,891.33 / $2,225.09 / $2,225.09
| Professional | | $1,891.33 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.94 / $1,243.16 / $1,800.96
| Professional | | $926.94 | $1,243.16 | $1,800.96 |