- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.56 / $2,395.19 / $3,814.17
| Professional | | $1,830.56 | $2,395.19 | $3,814.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,446.40
| Facility | | $2,446.40 | $2,446.40 | $2,446.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,079.44 / $2,446.40 / $4,372.50
| Professional | | $2,079.44 | $2,446.40 | $4,372.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.58 / $325.58 / $2,871.52
| Professional | | $325.58 | $325.58 | $2,871.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,435.76 / $1,675.05 / $3,129.89
| Professional | | $1,435.76 | $1,675.05 | $3,129.89 |