- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,854.79 / $3,743.84 / $4,266.22
| Professional | | $2,854.79 | $3,743.84 | $4,266.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,717.97 / $2,954.31 / $2,954.31
| Professional | | $2,717.97 | $2,954.31 | $2,954.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $3,428.15
| Facility | | $3,349.85 | $3,349.85 | $3,428.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.67 / $3,349.85 / $5,261.25
| Professional | | $356.67 | $3,349.85 | $5,261.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,451.10 / $2,031.54 / $2,902.20
| Professional | | $1,451.10 | $2,031.54 | $2,902.20 |