- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,328.19 / $3,138.47 / $3,320.96
| Professional | | $2,328.19 | $3,138.47 | $3,320.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.52 / $399.44 / $399.44
| Professional | | $339.52 | $399.44 | $399.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,349.85 / $3,349.85 / $3,349.85
| Facility | | $3,349.85 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,847.37 / $3,349.85 / $3,349.85
| Professional | | $2,847.37 | $3,349.85 | $3,349.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,616.80 / $2,003.52 / $3,339.20
| Professional | | $1,616.80 | $2,003.52 | $3,339.20 |