- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,075.82 / $2,722.33 / $2,851.89
| Professional | | $2,075.82 | $2,722.33 | $2,851.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,012.36 / $3,274.30 / $3,274.30
| Professional | | $3,012.36 | $3,274.30 | $3,274.30 |
- 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
- $844.13 / $1,465.36 / $2,110.33
| Professional | | $844.13 | $1,465.36 | $2,110.33 |