- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.78 / $2,845.89 / $3,013.29
| Professional | | $1,763.78 | $2,845.89 | $3,013.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,515.10 / $2,515.10 / $2,515.10
| Professional | | $2,515.10 | $2,515.10 | $2,515.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.31 / $2,416.31 / $2,416.31
| Facility | | $2,416.31 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.99 / $2,416.31 / $3,982.50
| Professional | | $257.99 | $2,416.31 | $3,982.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.07 / $1,266.20 / $2,541.57
| Professional | | $819.07 | $1,266.20 | $2,541.57 |